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Digitized  by  the  Internet  Archive 

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http://www.archive.org/details/manualofdiseasesOOruhr 


„ 


A   MANUAL 


OF   THE 


Diseases  of  Infants 


AND 


Children 


BY 

JOHN    RUHRAH,  M.D. 

PROFESSOR    OF    DISEASES    OF    CHILDREN    IN    THE    COLLEGE    OF 
PHYSICIANS    AND    SURGEONS,    BALTIMORE 


ILLUSTRATED 
Fourth  Edition,   Thoroughly  Revised 


PHILADELPHIA  AND   LONDON 

W.    B.   SAUNDERS    COMPANY 

1914 


*>•  i 


Copyright,  1905,  by  W.  B.  Saunders  and  Company.     Reprinted  August,  1906. 
Revised,  reprinted,  and  recopyrighted  February,  1908.    Revised,  re- 
printed,   and    recopyrighted    January,    1911.       Reprinted 
August,     1913.      Revised,     reprinted,    and    recopy- 
righted September,  1914. 


Copyright,  1914,  by  W.  B.  Saunders  Company. 


PRINTED    IN    AMERICA 


PRESS    OF 

W.    B.    SAUNDERS    COMPANY 

PHILADELPHIA 


E 


THIS    LITTLE    BOOK 


IS     AFFECTIONATELY    DEDICATED 


TO    MY    FATHER. 


PREFACE  TO  THE  FOURTH  EDITION. 


This  little  book  has  been  so  cordially  received  that  a 
fourth  edition  has  been  prepared  with  the  idea  of  bringing  it 
up  to  date.  Numerous  minor  changes  and  additions  have 
been  made,  and  among  these  may  be  mentioned  the  insertion 
of  an  article  on  pellagra  in  children,  the  use  of  the  soy  bean, 
and  some  other  methods  in  the  section  on  infant  feeding,  a 
chapter  on  drug  eruptions  and  a  full  account  of  the  Binet- 
Simon  test  for  the  mentality  of  children.  It  has  been  the 
aim  of  the  author  to  keep  the  book  a  small  one  so  that  the 
student  may  use  it  for  rapid  references  in  the  wards  or  clinics, 
and  it  will  also  be  found  useful  as  a  desk  book  for  practising 
physicians. 

The  references  throughout  the  book  will  be  found  of  great 
use  when  the  student  wishes  more  extended  information  than 
is  given  in  the  average  text-book.  For  the  most  part  these 
references  are  in  readily  accessible  journals  in  the  English 
language  and  the  articles  referred  to  contain,  in  most  instances, 
extensive  bibliographies. 

Baltimore,  Md.,  September,  1914. 


PREFACE. 


The  average  medical  student  attending  the  third  and 
fourth  sessions  has  about  fifteen  different  brandies  with 
which  to  familiarize  himself.  The  text-books  treating  of 
these  subjects  average  about  1000  pages  each,  or  a  total 
of  some  15,000  pages.  The  student  is  busy  all  day  at  the 
college  or  in  the  hospital.  In  the  evening  he  is  expected  to 
review  the  subjects  which  he  has  considered  during  the  day, 
as  well  as  fill  in  the  many  gaps  in  the  college  curriculum. 
Small  wonder  is  it  that,  as  the  German  proverb  puts  it,  he 
cannot  see  the  wood  for  the  trees. 

This  little  book  has  been  prepared  for  the  medical  student, 
not  to  supplant  the  larger  and  necessary  text-book,  but  to 
enable  the  student  to  grasp  quickly  the  more  important  parts 
of  the  subject  of  pediatrics,  and  to  furnish  him  with  a  rapid 
reference-book  for  clinical  use.  It  is  hoped  that  the  volume 
is  not  too  condensed  to  be  of  service  to  the  busy  practitioner. 

In  preparing  this  book  all  of  the  more  important  text- 
books have  been  consulted,  as  well  as  the  literature  as  found 
in  the  journals.  The  chapter  on  Infant  Feeding  has  been 
made  more  comprehensive  than  might  be  expected  in  a  work 
of  this  scope,  owing  to  the  great  importance  of  the  subject. 
A  large  number  of  references  to  journal  articles  have  been 
added  as  footnotes  to  enable  the  student  to  look  up  any 
given  subject  in  the  medical  library.  Almost  all  of  these 
references  will  be  found  to  contain  a  more  or  less  complete 

9 


10  PREFA  CE. 

bibliography  of  the  subject.  As  many  teachers  suggest  that 
students  look  up  various  topics  in  the  medical  library,  a  short 
chapter  has  been  added  on  this  subject. 

The  illustrations  are  partly  original  and  partly  from  other 
authors.  For  these  latter  the  writer  wishes  to  express  his 
obligations  to  the  authors  from  whom  they  have  been  bor- 
rowed. Many  thanks  are  also  due  to  Dr.  W.  E.  Magruder 
for  assistance  in  reading  the  proof  and  to  Messrs.  W.  B. 
Saunders  and  Company  for  their  courtesy  during  the  prepara- 
tion of  the  work. 


CONTENTS 


PAGE 

Care  of  the  Newborn 17 

The  Anatomic  and  Physiologic  Peculiarities  of  Infancy  and 

Childhood 20 

Teeth,  28 — Anatomic  Peculiarities,  29 — Premature  and 
Delicate  Infants,  34. 

The  Examination  of  Sick  Children 36 

Diseases  of  the  Newborn 50 

Asphyxia,  50 — Congenital  Atelectasis,  52 — Icterus,  53 — 
Acute  Infections,  54 — Pyogenic  Diseases,  54 — Ophthalmia 
Neonatorum,  56 — Tetanus,  58 — Pemphigus,  60 — Fatty  De- 
generation of  the  Newborn,  62 — Epidemic  Hemoglobinuria,  62 
— Hemorrhages,  63 — Intestinal  Obstruction,  65 — Diaphrag- 
matic Hernia,  66 — Mastitis,  66 — Umbilical  Hernia,  67 — 
Lesions  of  the  Umbilicus,  67 — Sclerema,  68 — Edema,  68 — 
Inanition  Fever,  68. 

Infant  Feeding 69 

Breast-feeding,  69 — Mixed  Feeding,  76 — Artificial  or  Bottle- 
feeding,  76 — Milk  Modification,  80 — Feeding  during  the  Sec- 
ond Year,  97 — Diet  from  Two  and  One-half  to  Six  Years,  100 — 
Diet  of  School  Children,  102 — Other  Factors  in  Infant  Feeding, 
106— The  Feeding  of  Sick  Infants,  109. 

Diseases  of  Nutrition 114 

Inanition,  114 — Marasmus,  115 — Malnutrition,  117 — Food 
Intoxications,  118 — Acid  Intoxication,  119 — Rachitis,  120 — 
Adolescent  Rachitis,  123 — Scurvy,  124 — Diabetes  Mellitus, 
126. 

Diseases  of  the  Mouth  and  Pharynx 128 

Perleche,  128— Harelip,  128— Cleft  Palate,  129— Congenital 
Hypertrophy  of  the  Tongue,  130 — Other  Deformities,  130 — 
Epithelial  Desquamation  of  the  Tongue,  130 — Glossitis,  130 — 
Tongue  Swallowing,  L31 — Ulcer  of  the  Frenum,  131 — Riga's 
Disease,  131 — Alveolar  Abscess,  131 — Difficult  Dentition,  131 
— Diseases  of  the  Uvula,  132 — Bednar's  Aphthae,  132 — 
Catarrhal  Stomatitis,  133 — Herpetic  Stomatitis,  133 — Thrush, 
133 — Ulcerative  Stomatitis,  134 — Gangrenous  Stomatitis,  135 
—Other  Forms  of  Stomatitis,  136. 

11 


12  CONTENTS. 

PAGE 

Diseases  of  the  Tonsils  and  Esophagus 137 

Croupous  Tonsillitis,  137 — Ulceromembranous  Tonsillitis, 
137— Follicular  Tonsillitis,  137— Phlegmonous  Tonsillitis,  139 
— Chronic  Hypertrophy  of  the  Tonsils,  140 — Retropharyngeal 
Abscess,  140 — Acute  Pharyngitis,  142 — Retro-esophageal 
Abscess,  142 — Inflammation  of  the  Esophagus,  142 — Mal- 
formations of  the  Esophagus,  143. 

Diseases  of  the  Stomach 144 

Vomiting,  144 — Cyclic  Vomiting,  144 — Gastralgia,  145 — 
Acute  Gastric  Indigestion,  146 — Acute  Gastritis,  147 — Chronic 
Gastric  Indigestion,  148 — Dilatation  of  the  Stomach,  149 — 
Congenital  Stenosis  of  the  Pylorus,  150 — Ulcer  of  the  Stomach, 
151 — Tumors  of  the  Stomach,  151 — Hematemesis,  151. 

Diseases  of  the  Intestines 152 

Malformations  of  the  Intestines,  152 — Congenital  Absence 
of  the  Abdominal  Muscles,  152 — Gastroduodenitis,  153 — 
Diarrhea,  154 — Acute  Intestinal  Indigestion,  155 — The  Infec- 
tious Diarrheal  Diseases,  157 — Acute  Gastro-enteritis,  157 — 
Acute  Ileocolitis,  161 — Chronic  Ileocolitis,  162 — Amyloid 
Degeneration  of  the  Intestines,  163 — Amebic  Colitis,  164 — 
Chronic  Intestinal  Indigestion,  164 — Intestinal  Colic,  165 — 
Chronic  Constipation,  166 — Intussusception,  167 — Appen- 
dicitis, 168 — Dilatation  and  Hypertrophy  of  the  Colon,  170 — 
Intestinal  Worms,  171 — Diseases  of  the  Rectum,  174. 

Diseases  of  the  Peritoneum 176 

Peritonitis,  176 — Ascites,  177 — Chylous  Ascites,  178. 

Diseases  of  the  Liver 179 

Chronic  Family  Jaundice,  180. 

Respiratory  System  of  Infants  and  Children 181 

Coryza,  182 — Chronic  Nasal  Catarrh,  183 — Adenoids,  184 — 
Diseases  of  the  Larynx,  187 — Catarrhal  Spasm  of  the  Larynx, 
187 — Acute  Catarrhal  Laryngitis,  189 — Edema  of  the  Glottis, 
190 — Chronic  Laryngitis,  190 — Tumors  of  the  Larynx,  191 — 
Foreign  Bodies  in  the  Larynx,  191 — Laryngismus  Stridulus, 
192 — Congenital  Laryngeal  Stridor,  192 — Diseases  of  the 
Bronchi  and  Lungs,  193 — Bronchitis,  193 — Acute  Catarrhal 
Bronchitis,  193 — Fibrinous  Bronchitis,  195 — Chronic  Bron- 
chitis, 195 — Bronchiectasis,  196 — Nervous  Cough;  Reflex 
Cough,  197 — Asthma,  197 — Pneumonia,  198 — Bronchopneu- 
monia, 199 — Lobar  Pneumonia,  205 — Hypostatic  Pneumonia, 
207 — Pleuropneumonia,  208 — Chronic  Interstitial  Pneumonia, 
208 — Gangrene  of  the  Lung,  209 — Emphysema,  209 — Pleurisy, 
210— Empyema,  212. 

Heart  and  Circulation  in  Infancy  and  Childhood 214 

The  Heart  in  Older  Children,  215 — Congenital  Heart  Dis- 
ease, 217 — Pericarditis,  219 — Other  Pericardial  Lesions,  221 — 


CONTENTS.  13 

PAGE 

Chronic  Pericarditis  with  Adhesions,  222 — Endocarditis,  222 — 
Chronic  Valvular  Disease,  224 — Myocarditis,  228 — Hemic  and 
Functional  Murmurs,  229 — Functional  Heart  Disorders,  229 — 
Diseases  of  the  Blood-vessels,  230. 

The  Blood  in  Infancy  and  Childhood 231 

Frequency  of  the  Various  Forms  of  Leukocytes,  235 — Sig- 
nificance of  Blood  Changes,  235 — Blood  Changes  in  Disease, 
236 — Chlorosis,  237 — Pernicious  Anemia,  238 — Secondary 
Anemia,  239 — Leukemia,  240 — Splenic  Anemia  of  Infants, 
241 — Hemophilia,  242 — Purpura,  243 — Purpuric  Diseases,  244. 

Diseases  of  the  Ductless  Glands 246 

Hodgkin's  Disease,  246 — Status  Lymphaticus,  247 — Simple 
Acute  Adenitis,  248 — Simple  Chronic  Adenitis,  249 — Diseases 
of  the  Thymus  Gland,  250 — The  Adrenals,  251 — Addison's 
Disease,  251 — The  Spleen,  251 — Primary  Splenomegaly,  253 — 
Dystrophia  Adiposogenitalis,  253. 

The  Urine  in  Infancy  and  Childhood 254 

Functional  Albuminuria,  255 — Hematuria,  256 — Hemo- 
globinuria, 256 — Glycosuria,  256 — Pyuria,  257 — Lithuria, 
257 — Indicanuria,  257 — Acetonuria,  258 — Diaeeturia,  258 — 
Anuria,  258 — Diminution  of  Urine,  258 — Diabetes  Insipidus, 
259 — Diseases  of  the  Kidneys,  259— Malformations  and  Mal- 
positions of  the  Kidney,  259- — Uric  Acid  Infarctions,  260 — 
Hyperemia  of  the  Kidney,  260 — Acute  Congestion  of  the 
Kidney,  260 — Chronic  Congestion  of  the  Kidney,  261 — 
Inflammation  of  the  Kidney,  261 — Acute  Nephritis,  261 — 
Chronic  Nephritis,  264 — Amyloid  Degeneration  of  the  Kidney, 
236— New  Growths  in  the  Kidney,  267— Pyelitis,  267— 
Cystitis  and  Cystopyelitis,  268 — Renal  Calculi,  269 — Peri- 
nephritis, 270. 

The  Genital  Organs 271 

Malformations  of  the  Genitalia,  271 — Diseases  of  the  Male 
Genitals,  272— Diseases  of  the  Female  Genitalia,  272— Dis- 
eases of  the  Bladder,  274. 

Diseases  of  the  Skin 277 

Congenital  Ichthyosis,  277 — Eczema,  278 — Dermatitis  Ven- 
enata, 280— Miliaria,  278— Seborrhea  of  the  Scalp,  282— Fu- 
runculosis,  283 — Impetigo  Contagiosa,  283 — Echthyma,  285 — 
Urticaria,  285— Alopecia  Areata,  286— Pediculosis,  288— 
Scabies,  289— Ringworm,  290— Favus,  291— Gangrene,  292— 
Drug  Eruptions,  293. 

Acute  Otitis 294 

Diseases  of  the  Nervous  System 296 

The  Examination  of  the  Nervous  System  and  the  Signifi- 
cance of  Symptoms,  296 — Convulsions,  301 — Epilepsy,  303 — 


14  CONTENTS. 

PAGE 

Tetany,  305 — Laryngismus  Stridulus,  306 — Chorea,  307 — 
Other  Spasmodic  Affections,  309 — Hysteria,  312 — Tic,  313 — 
Headache,  313 — Disorders  of  Sleep,  314 — Speech  Disturb- 
ances, 315 — Wyllie's  Physiologic  Alphabet,  316 — The  In- 
jurious Habits  of  Infancy  and  Childhood,  319 — Angioneurotic 
Edema,  320— Exophthalmic  Goiter,  320— Malformations,  320 
— Birth  Palsies,  323 — Inflammation  of  the  Brain  and  Its 
Membranes,  326 — Chronic  Basilar  Meningitis  in  Infants,  328 — 
Thrombosis  of  the  Sinuses,  330 — Abscess  of  the  Brain,  330 — 
Cerebral  Tumors,  331 — Hydrocephalus,  332 — Infantile  Cere- 
bral Paralysis,  334 — Myasthenia  Gravis,  337 — Idiocy,  337 — 
Cretinism,  346 — Infantilism,  349 — Achondroplasia,  350 — 
Dwarfism,  351 — Cleidocranial  Dystosis,  352 — Insanity,  352 — 
Developmental  or  Juvenile  General  Paralysis,  352 — Stigmata 
of  Degeneration,  353 — Deaf-mutism,  354. 

Diseases  of  the  Spinal  Cord 355 

Malformations,  355 — Spinal  Meningitis,  356 — Myelitis,  356 
— Compression  Myelitis,  357 — Tumors  of  the  Spinal  Cord,  358 
— Syringomyelia,  358 — Hereditary  Ataxia,  358 — Cerebellar 
Hereditary  Ataxia,  359 — Landry's  Paralysis,  360 — Atrophies 
of  Nervous  Origin,  360 — The  Progressive  Muscular  Dystro- 
phies, 362 — Peroneal  Muscular  Atrophy,  365 — Hypertrophic 
Interstitial  Neuritis,  365 — Multiple  Neuritis,  366 — Facial 
Paralysis,  368 — Diphtheritic  Paralysis,  368. 

Acute  Infectious  Diseases 370 

The  Transmission  of  Infectious  Diseases,  370 — Scarlet 
Fever,  371 — Measles,  375 — German  Measles,  381 — Erythema 
Infectiosum,  384 — Varicella,  385 — The  Fourth  Disease,  387 — 
Vaccinia,  388— Pertussis,  390— Mumps,  394— Diphtheria,  396 
— Typhoid  Fever,  409 — Cerebrospinal  Fever,  413 — Anterior 
Poliomyelitis,  419 — Influenza,  424 — Epidemic  Pneumococcic 
Infections,  425 — Tuberculosis,  425 — Acute  General  Miliary 
Tuberculosis,  428 — Tuberculosis  of  the  Respiratory  Organs, 
429 — Tuberculous  Bronchitis,  432 — Tuberculous  Meningitis, 
432 — Tuberculous  Adenitis,  435 — Tuberculosis  of  the  Bron- 
chial Lymph-nodes,  436 — Tuberculosis  of  the  Intestines  and 
Mesenteric  Lymph-nodes,  437 — Tuberculous  Peritonitis,  438 
— Tuberculosis  of  the  Kidney,  440 — Syphilis,  440 — Malaria, 
451 — Hook-worm  Disease,  455 — Rheumatism,  457 — Chronic 
Fibrous  Rheumatism,  460. 

Diseases  of  the  Joints 461 

Arthritis  Deformans,  461 — Acute  Arthritis  of  Infants,  462 — 
Tuberculous  Arthritis  and  Ostitis,  463 — Other  Forms  of 
Arthritis,  468. 

Diseases  of  the  Bones 471 

Acute  Osteomyelitis,  471 — Multiple  Exostoses,  471 — 
Osteogenesis  Imperfecta,  471. 


CONTENTS.  15 

PAOE 

Diseases  Not  Otherwise  Classified 473 

Pellagra,  473. 

Therapeutics  for  Infants  and  Children 470 

Size  of  the  Dose  of  Medicine,  476 — Antipyretics,  481 — 
Anesthetics,  483 — Opiates,  484 — Somnifacients,  485— Stimu- 
lants, 485 — Tonics,  487 — Alteratives,  488 — Stomachics,  490 — 
Digestants,  491 — Cathartics,  491 — Diuretics,  492 — Diaphoret- 
ics, 493 — Expectorants,  493 — Antacids,  496 — Anthelmintics, 
496 — Astringents,  496 — Antirheumatic  Remedies,  497 — Anti- 
spasmodics, 498 — Urogenital  Antiseptic,  498 — Vasomotor 
Stimulant,  499 — Antimalarial  Remedies,  499 — Remedies  for 
Common  Skin  Diseases,  499 — Escharotics,  501 — Stomach 
Washing,  501 — Irrigation  of  Colon,  501 — Enemata,  502 — 
Hot-air  Bath,  503— Hot  Pack,  503— Hot  Bath,  503— Salt 
Bath,  503— Soda  Bath,  503— Bran  Bath,  503— Starch  Bath, 
503 — Counterirritants,  503 — Liniments,  504 — Inhalations, 
505 — Nasal  Sprays  and  Washes,  505 — Subcutaneous  Injec- 
tion of  Saline  Solution,  505 — Vaccine  Therapy,  506. 

The  Medical  Inspection  of  School  Children 508 

School  Hygiene,  508— The  Eyes,  508— The  Ears,  509— The 
Nose  and  Throat,  510— The  Teeth,  511— Mentally  Defective 
Children,  511 — Nervous  Diseases,  512 — Physical  Defects,  513 
— Skin  Diseases,  514 — Other  Symptoms,  514 — Infectious 
Diseases,  515. 

The  Measuring  of  the  Development  of  the  Intelligence 

of  Children 518 

Sample  Pamphlet  of  Information  for  Distribution  Among 

the  Poor  in  Summer 526 

Directions  to  Mothers  of  Mentally  Defective  Children,  528 — 
Home-made  Refrigerator,  529. 

Pediatric  Literature 531 

Index 533 


MANUAL  OF  THE  DISEASES 

OF 

INFANTS  AND   CHILDREN. 


CARE   OF  THE    NEWBORN. 

Care  of  the  Cord. — Dust  with  powdered  starch  (19 
parts)  and  salicylic  acid  (1  part),  and  cover  with  sterile 
gauze.  Avoid  strong  antiseptics,  as  they  delay  separation 
— which  normally  occurs  about  the  fifth  day.  When  the 
cord  drops  off  a  small  pad  of  gauze  should  be  placed  over 
the  umbilicus  and  held  in  place  with  the  abdominal  binder. 
This  prevents  the  formation  of  umbilical  hernia. 

Care  of  the  I£yes. — Prevent  gonorrheal  ophthalmia 
and  possible  blindness.  In  every  case,  in  hospital  and  in 
private  practice,  where  the  mother  has  a  purulent  discharge 
from  the  vagina  the  child  should  receive  a  drop  or  two  of  a 
1 0  per  cent,  solution  of  protargol  or,  preferably,  of  a  2  per  cent, 
solution  of  silver  nitrate.  When  the  mother  is  free  from  any 
suspicious  discharge  a  solution  of  boric  acid  (10  gr.  to  1  oz.) 
may  be  substituted.  This  latter  may  be  used  daily  during 
early  life  if  there  is  any  tendency  to  inflammation  about  the 
eyes.  The  eyes  of  the  infant  should  be  protected  from  strong 
lights. 

Bathing. — After  birth  the  child  should  be  thoroughly 
oiled,  to  facilitate  the  removal  of  the  vernix  caseosa,  and 
bathed  in  warm  water  (100°  F.).  After  this,  until  the  cord 
separates,  a  sponge  bath  only  should  be  used.  After  that  a 
full  bath  once  daily. 

2  17 


18  DISEASES  OF  INFANTS  AND  CHILDREN. 

Temperature  of  the  Bath  for  Healthy  Infants. 

Up  to  six  months 98°  F. 

Six  to  twelve  months 95°  F. 

One  to  two  years 90°  F. 

The  bath  should  be  given  in  a  warm  room,  preferably 
before  an  open  fire.  Older  children  may  have  a  cold  douche 
(70°  F.),  for  half  a  minute,  at  the  end  of  the  bath.  If  the 
child  does  not  react  after  the  bath,  and  becomes  pale  and  blue 
about  the  lips  and  finger-nails,  the  full  bath  is  doing  harm, 
and  a  warm  sponge  should  be  substituted.  If  the  skin  is 
chafed,  or  if  eczema  is  present,  a  handful  of  common  salt  or 
sea  salt  may  be  added  to  the  bath,  or  a  bran  or  starch  bath 
may  be  used  instead. 

Clothing". — The  clothing  should  be  suited  to  the  season 
and  to  the  weather.  The  child  is  to  be  kept  warm  with 
light,  loose  unirritating  clothing.  There  is  great  liability  to 
overclothe.  The  abdominal  binder  should  be  used  for  the 
first  few  months,  after  which  it  may  be  dispensed  with, 
unless  the  child  is  thin  or  suffers  from  colic.  A  long  flannel 
band  is  best  for  the  first  month,  after  which  a  knit  band, 
with  shoulder-straps,  should  be  used.  Diapers  or  napkins 
should  be  soft  and  warm.  Canton  flannel  or  stockinet  is  the 
best.  The  arms  and  legs  should  be  covered  in  cold  weather. 
The  child  should  not  sleep  at  night  in  the  clothing  which  it 
wears  during  the  day.  A  union  suit  with  feet  is  best  for 
older  children.  The  child  should  not  be  overloaded  with 
bedclothes,  but  should  be  comfortably  warm. 

Mouth  and  Teeth. — The  mouth  should  be  kept  clean 
with  plain  water.  Should  thrush  appear  or  the  mouth  be- 
come inflamed,  boric  acid  solution  (10  gr.  to  1  oz.)  should  be 
used.  Borax  or  sodium  bicarbonate  (20  grs.  to  1  oz.)  is  also 
useful.  The  teeth  should  be  kept  clean,  and  carious  teeth 
filled  or  removed. 

Too  much  stress  cannot  be  laid  on  the  care  of  the  tempo- 
rary teeth.  If  they  are  neglected  and  become  decayed  the) 
are  a  source  of  danger,  as  the  child  is  constantly  absorbing 
toxic  material.  They  also  cause  enlarged  glands  or  even 
abscesses  in  the  neck.     When  the  teeth  are  bad,  mastication 


CARE  OF  THE  NEWBORN.  19 

is  difficult  or  impossible  ;  the  child   may  Buffer  from  ind  _ 

tion  in  const'ijiicnce,  or  be  unable  to  take  the  proper  amount 
of  food.  The  loss  of  the  first  teeth  may  cause  the  second 
t<<  th  to  be  irregular  and  out  of  alignment.  The  second 
teeth  should  receive  most  careful  care,  all  carious  spot-  being 
filled  as  soon  as  discovered.  The  first  molars  are  often  lost, 
as  they  are  mi-taken  for  temporary  teeth  and  allowed  to 
decay.  Where  the  teeth  are  not  in  alignment  or  are  irregular, 
a  well-trained  denti.-t  can  usually  straighten  them,  but  the 
treatment  must  be  begun  early  and  continued  over  long 
periods  of  time. 

Care  of  the  Skin. — Chafing  and  eczema  are  common  in 
infancy.  The  use  of  clothing  which  does  not  bind  or  irri- 
tate, plain  Castile  soap,  and  bland  unirritating  powder  will 
prevent  much  trouble.  Napkins  should  be  changed  as  soon 
as  they  are  soiled,  and  the  child  dried  and  powdered.  If 
irritation  is  already  present  the  child  should  be  wiped  with 
an  oiled  cloth  and  then  powdered.  Oxid  of  zinc  ointment 
and  stearate  of  zinc  powder  are  also  useful.  Salt,  starch,  or 
bran  baths  may  be  used. 

Care  of  the  Genital  Organs. — In  girls  the  genitals 
should  be  kept  clean,  as  neglect  leads  to  vulvo- vaginitis.  In 
boys  the  foreskin  should  be  retracted  during  the  first  few 
weeks.  If  this  cannot  be  done,  and  the  preputial  orifice  is 
very  small,  the  child  should  be  circumcised.  The  foreskin 
should  be  retracted  daily,  and  the  parts  cleansed. 

Vaccination. — Every  healthy  child  should  be  vacci- 
nated before  the  fifth  month. 

Training  the  Bladder. — This  can  usually,  not  always, 
be  accomplished  by  the  end  of  the  first  year  by  persistent 
efforts.  The  child  should  be  instructed  to  indicate  when  he 
wishes  to  empty  his  bladder. 

Training  the  Bowels. — The  child  should  be  placed  on 
a  small  chamber  about  the  time  that  it  usually  has  a  stool. 
Just  after  a  morning  feeding  is  the  best  time.  The  back 
should  be  supported.  Training  should  be  begun  early — 
before  the  third  month — and  persisted  in  until  regular  habits 
are  established.     Regular  habits   and  regular  bowels  mean 


20  DISEASES  OF  INFANTS  AND  CHILDREN. 

health   for  the   child   and   much  saving  of  trouble  for  the 
nurse. 

Care  of  the  Nervous  System. — The  child  should  be 
kept  quiet,  and  its  surroundings  carefully  regulated.  Only 
simple  toys  should  be  allowed  during  the  first  two  years. 
Romping  with  young  infants  is  injurious.  After  4  o'clock 
in  the  afternoon  the  child  should  be  kept  very  quiet. 

THE  ANATOMIC  AND  PHYSIOLOGIC  PECULIAR- 
ITIES OF  INFANCY  AND  CHILDHOOD. 

For  further  information  the  reader  is  referred  to  the  arti- 
cles on  the  different  organs,  and  to  Dwight\s  Frozen  Sections 
of  a  Child,  Stratz's  Der  K'orper  des  Kindes,  Rotch's  Text- 
booh,  Stanley  Hair's  Adolescence. 

Sleep. — The  newborn  child  sleeps  soundly  for  several 
days ;  later  it  sleeps  less  soundly ;  but  after  three  years  of 
age  the  sleep  is  very  profound. 

Average  Length  of  Time  for  a  Child  to  Sleep. 

First  month 20-22  hours. 

One  to  six  months 16-18  " 

Six  to  twelve  months 15-17  " 

One  to  two  years 14-15  " 

Two  to  three  years 13-14  " 

Three  to  four  years 12-13  " 

Four  to  five  years 11-12  " 

Five  to  ten  years 9-11  " 

Ten  to  fifteen  years      9-10  " 

One  or  two  daily  naps  are  taken  until  about  four  years  of 
age.  Dry  napkins,  a  satisfied  appetite,  and  a  quiet  darkened 
room,  are  all  that  is  necessary.  Good  habits  should  be 
established  early.  Rocking  to  sleep  is  not  necessary,  and,  if 
properly  trained,  an  infant  will  sleep  without  it.  Occasion- 
ally a  child  is  found  which  cannot  be  trained  to  regular 
habits  of  sleep,  but  this  is  much  more  rare  than  is  usually 
supposed. 

Exercise. — The  average  infant  in  a  family  gets  suffi- 
cient exercise.  In  hospitals  and  asylums  the  babes  do  not. 
They  should  be  picked  up  and  carried  about  the  room,  and^ 


PECULIARITIES   OF  INFANCY  AND   CHILDHOOD.     21 

wherever  possible,  not  fed  in  their  cribs.  For  older  children 
out-of-door  exercise  is  necessary. 

Airing. — In  summer  and  in  suitable  temperatures  a  child 
may  be  taken  out-of-doors  at  the  end  of  the  first  week'. 
Sleeping  out-of-doors  is  not  injurious.  In  winter  it  should 
be  accustomed  to  the  fresh  air  by  dressing  as  if  for  the  street 
and  then  opening  the  window.  The  first  airing  may  be 
fifteen-minutes  long,  and  lengthened  from  day  to  day  until 
it  may  be  taken  out  in  fine  weather.  Avoid  high  winds, 
wet,  raw  days,  and  very  low  temperatures.  Otherwise,  the 
little  one  should  spend  as  much  of  its  time  in  the  open  air  as 
possible.  The  room  in  which  it  sleeps  should  be  well-aired 
and  ventilated. 

The  Nursery. — Choose  a  light  well-ventilated  room. 
If  heated  by  a  furnace  or  steam  radiators,  supply  moisture 
by  having  a  pan  of  water  in  the  room.  Avoid  gas  stoves. 
The  furniture  of  the  nursery  should  be  plain  and  easily 
cleaned.  The  temperature  should  be  70°  F.  (68°  is  prefer- 
able to  72°).  At  night,  during  the  first  year,  65°  F. ;  later, 
the  temperature  may  fall  to  50°  F.  Have  plenty  of  fresh 
air.  Infants  require  about  1000  cubic  feet  of  air-space; 
older  children  several  hundred  less. 

Weight.1 — The  weight  is  of  especial  value  in  early 
life,  and  it  is  the  best  index  of  the  nutrition.  If  the 
child  is  not  gaining  regularly,  it  means  something  is 
wrong.  The  infant  should  be  weighed  once  a  week  for 
the  first  six  months ;  after  that,  twice  a  month.  The 
weighing  should  not  be  done  by  the  mother  or  in  her  pres- 
ence if  she  is  nursing  it,  as  a  loss  of  weight  may  cause  such 
a  strong  mental  impression  that  her  milk  secretion  may  be 
inhibited.  The  average  child  weighs  a  trifle  over  7  pounds 
at  birth.  The  first  two  days  it  loses  about  11  per  cent,  of 
the  original  weight.  This  is  called  the  physiologic  loss  of 
weight.  After  the  third  day  the  child  begins  to  gain.  During 
the  first  six  months  4  ounces  is  an  average  weekly  gain  ; 
later,  it  is   slightly  less.     At  the   end  of  the  first  year  the 

1  See  Boas,  Science,  Apr.  2,  1895. 


22 


DISEASES  OF  INFANTS  AND   CHILDREN. 


infant  weighs  about  three  times  its  weight  at  birth.  The 
average  gain  during  the  second  year  is  6,  during  the  third 
year  4J,  and  during  the  fourth  year  4  pounds. 

Height. — The  average  length  at  birth  is  about  20.5  in. 
(55  cm.).  During  the  first  year  there  is  an  average  gain  of 
about  8  in.  (21  cm.).  During  the  second  year  the  gain  is 
about  3J  in.  (9  cm.),  and  thereafter  the  average  gain  is  about 
2J  in.  (6J  cm.)  a  year  until  the  eleventh  year,  when  the 
growth  becomes  more  rapid. 

Closure  of  the  Sutures.— Ossification  is  usuallvcom- 


1 


15  Q  13  17  21 

Fig.  1.— Diagram  showing  proportionate  growth  of  different  parts  of  the  hody  at 
various  ages  from  1  to  21  years  (J.  P.  C.  Griffith). 

plete  by  the  sixth  month.  It  may  be  delayed  until  the 
ninth  month.  Distinct  separation  after  birth  is  abnormal, 
and  is  usually  due  to  premature  birth  or  syphilis. 

Closure  of  the  Fontanels. — The  posterior  fontanel 
closes  about  the  end  of  the  second  month  ;  the  anterior  about 
the  eighteenth  month.  There  is  considerable  variation  in 
the  time  of  closure.  After  two  years  an  open  fontanel  is 
abnormal  and  is  usually  due  to  rickets.  Cretinism  may  be 
a  cause. 


PECULIARITIES   OF  INFANCY  AND   CHILDHOOD.     23 


Rate  of  Growth  in  Height  of  American  Children  (Boas). 


Approximate 
average  age. 

Number  of 
observations. 

Boys. 

Average  height 
for  each  year. 

Absolute  annual 
increase. 

Annual 
increase. 

Years. 

5* 

6* 

n 

8* 

9* 

10* 

11* 

12* 

13* 

14* 

15* 

16* 

17*  ....    . 
18* 

1535 

3975 

5379 

5633 

5531 

5151 

4759 

4205 

3573 

2518 

1481 

753 

429 

229 

Inches. 
41.7 
43.9 
46.0 
48.8 
50.0 
51.9 
53.6 
55.4 
57.5 
60.0 
62.9 
64.9 
66.5 
67.4 

Inches. 

2.2 
2.1 
2.8 
1.2 
1.9 
1.7 
1.8 
2.1 
2.5 
2.9 
2.0 
1.6 
0.9 

Per  cent. 

5.3 

4.8 

6.1 

2.5 

3.8 

3.3 

3.4 

3.8 

4.3    ■ 

4.8 

3.2 

2.5 

1.4 

Rate  of  Growth  in  Height  of  American  Children  (Boas). 


Number  of 
observations. 

Girls. 

average  age. 

Average  height 
for  each  year. 

Absolute  annual 
increase. 

Annual 
increase. 

Years 

5* 

6* 
7* 
8* 

9* 
10* 

11* 
12* 
13* 
14* 
15* 
16* 
17* 
18* 

. 

1260 
3618 
4913 
5289 
5132 
4827 
4507 
4187 
3411 
2537 
1656 
1171  • 
790 

Inches. 
41.3 
43.3 
45.7 
47.7 
49.7 
51.7 
53.8 
56.1 
58.5 
60.4 
61.6 
62.2 
62.7 

Inches. 

2.0 
2.4 
2.0 
2.0 
2.0 
2.1 
2.3 
2.4 
1.9 
1.2 
•     0.6 
0.5 

Per  cent. 

4.8 
5.5 
4.4 
'     4.2 
4.0 
4.1 
4.3 
4.3 
3.2 
2.0 
1.0 
0.8 

24 


DISEASES   OF  INFANTS  AND  CHILDREN 


Weight  of  American  Children  (Burke). 

Boys. 

Age. 

Average  for  each 

Absolute  annual 

Annual  increase. 

age. 

increase. 

Years. 

Pounds. 

Pounds. 

Per  cent. 

6* 

45.2 

7*    • 

49.5 

4.3 

9.5 

8*    . 

54.5 

5.0 

10.1 

9*    . 

59.6 

5.1 

9.3 

10*   . 

65.4 

5.8 

9.7 

n*  • 

70.7 

5.3 

8.1 

12*    . 

76.9 

6.2 

8.7 

13*    . 

84.8 

7.9 

10.3 

14*    . 

95.2 

10.4 

12.3 

15|    • 

107.4 

12.2 

12.8 

16*    . 

8 

121.0 

13.6 

12.7 

171 

18* 

Weight  of  American  Children  (Burke). 


GlRLS 

Age. 

Average  for  each 
age. 

Absolute  annual 
increase. 

Aunual  increase. 

Years. 

6* 

7* 

8*    .......    . 

9* 

10* 

ii* 

12* 

13* 

14* 

15* 

16* 

17* 

18* • 

Pounds. 

43.4 

47.7 

52.5 

57.4 

62.9 

69.5 

78.7 

88.7 

98.3 
106.7 
112.3 
115.4 
114.9 

Pounds. 

4.3 
4.8 
4.9 
5.5 
6.6 
9.2 
10.6 
9.6 
8.4 
5.6 
3.1 

Per  cent. 

9.9 
10.0 

9.3 

9.6 
10.5 
13.2 
12.7 
11.9 

8.5 

5.2 

2.8 

INFANT'S  WEIGHT  CHART. 


Name, . 


Date  of  Birth,. 


u   .l    ,       ,       j       i  6       e       1  8       »       10      11       IS   IS   H   IJ   It   1?   18   10   SO   Jl   IS   2J   It 


Pounds 


Weeks,  i     s     t     '•     »    n    u    is   n    »    *» 


a  a  w   s»  »i   »»  »   »    »»   «l  «»«•««»    »>      "   60  6*  ** 


"?»     If     »     H     K     II    »    »00  10* 


PECULIARITIES  OF  INFANCY  AND  CHILDHOOD.     25 

Si^e  of  the  Head.— Thomson  gives  the  following  fig- 
ures for  the  size  of  the  head  : 

At  birth 13  to  13|  inches. 

At  six  months 16  inches. 

At  one  year 18  inches. 

At  two  years 19  inches. 

At  five  years 20  to  20£  inches. 

At  ten  years 21  inches. 

There  are,  however,  a  great  many  normal  variations  in  the 
size  as  well  as  in  the  shape  of  the  head. 

Shape  of  the  Head. — Congenital  deformities  are  fre- 
quently seen.  These  usually  disappear  early.  Deformities 
due  to  difficult  labor  are  generally  corrected  by  the  end  of 
the  first  month.      Lying   in   one  position  may  change  the 


Fig.  2.— Natiform  cranium. 

shape  of  the  head,  as  may  also  premature  ossification  of  the 
sutures.  A  square  head,  with  prominent  bosses,  is  seen  in 
rickety  children.  (See  also  Microcephalus  and  Hydro- 
cephalus.) 

The  Chest. — At  birth  the  anteroposterior  and  transverse 
diameters  of  the  chest  are  about  equal.  As  the  child  grows, 
the  transverse  becomes  longer  and  the  chest  assumes  an 
elliptical  shape. 

Muscular  Development. — Voluntary  movements  usu- 
ally begin  about  the  fourth  month.  At  this  time  the  head 
can  be  held  up.  Near  the  seventh  month  the  child  can  sit 
erect,  and  about  the  tenth  month  it  can  stand.  Walking  is 
begun  toward  the  twelfth  month,  and  the  child  can  usually 


26  DISEASES  OF  INFANTS  AND   CHILDREN. 

walk  alone  by  the  fifteenth  month.     There  are  great  varia- 
tions, however.     In  asylums  the  children  walk  late.1 

Special  Senses. — Sight. — After  the  first  week  the  child 
can  usually  distinguish  the  difference  between  light  and  dark- 
ness, and  will  very  often  follow  a  light  about  with  the  eyes. 
Toward  the  third  month  the  mother's  face  or  other  familiar 
objects  may  be  recognized,  and  in  about  the  sixth  mouth 
various  things  are  recognized.     The  color  sense  is  slow  in 
developing.     The  difference  between  red  and  yellow  may  be 
noted  during  the  first  year,  but  blue  and  green  may  not  be 
distinguished  for  a  year  or  two  later.     It  is  important  to 
recognize  whether  the  child  is  blind  or  not.     Older  children 
are  tested  in  the  same  manner  as  adults,  and   in   younger 
children  various  tests  may  be  made,  by  seeing  if  the  pupils 
contract  to  light  and,  after  a  few  months  of  age,  to  accom- 
modation ;  by  seeing  if  the  eye  is  winked  on  bringing  the 
finger  close  to  the  cornea  without  touching  it  (this  test  is  of 
no  value  under  two  months  of  age)  ;  by  seeing  whether  the 
child  recognizes  a  bottle  or  other  object  when  it  is  approached 
without  making  any  noise  ;  by  seeing  if  the  eyes  follow  a 
light  or  bright  objects.     Ophthalmoscopic  examinations  are 
valuable.     It  should  be  remembered  that  the  choroidal  pig- 
ment is  irregularly  distributed  in  infants  and  may  be  mis- 
taken for  diseased  conditions.     Amaurotic  family  idiocy  can 
only  be  diagnosed  by  ophthalmoscopic  examination.     If  the 
child  does  not  see  and  the  fundus  of  the  eye  is  normal,  one 
should  suspect  mental  deficiency.     Temporary  amaurosis  is 
sometimes    seen,   however,   after    coma,    convulsions,   severe 
whooping-cough,  and  basic  meningitis.    The  condition  known 
as  congenital  word  blindness2  should  be  borne  in  mind,  as 
children  so  afflicted  may  be  mistaken  for  idiots. 

Training  of  Blind  Children.3 — It  is  important  to  treat 
them  as  nearly  like  normal  children  as  possible,  and  this 
should  be  begun  earlv.  Thev  should  be  taught  to  exer- 
cise,  to  wash  and  dress  and   feed   themselves,  to  play  with 

1W,  Preyer,  The  Senses  and  the  Will,  1888;  The  Development  of  the 
Intellect,  1889.     Fred.  Tracy,  The  Psychology  of  Childhood, 

2  Hinshel  Wood,  Lancet,  May  26,  1900,  p.  1506. 

3  Drummond,  Pediatrics,  June,  1899. 


PECULIARITIES  OF  INFANCY  AXD  CHILDHOOD.     27 

toys  of  all  kinds,  and  to  indulge  in  games  with  other  chil- 
dren. All  of  these  things  make  a  good  foundation  for  the 
subsequent  training  of  the  child.  Above  all,  they  should  be 
prevented,  as  tar  as  possible,  from  acquiring  the  numerous 
disagreeable  habits,  as  twitching,  swaying,  moving  the  head, 
etc.,  to  which  blind  children  are  especially  prone. 

Hearing. — The  child  is  usually  deaf  at  birth,  and  this 
persists  for  two  or  three  days.  Loud  noises  are  usually 
recognized  at  the  end  of  the  first  or  second  week,  and  if  at 
the  end  of  two  months  the  child  dues  not  pay  any  attention 
to  loud  noises  it  should  be  suspected  of  being  either  deaf  or 
idiotic.  Deafness  rnav  come  on  during  childhood,  and  that 
which  is  seen  apart  from  visible  changes  in  the  ear  is  apt  to 
have  a  grave  prognosis,  such  as  that  following  whooping- 
cough,  meningitis,  and  various  infectious  diseases  where  the 
middle  ear  is  not  involved. 

The  Early  Training  of  Deaf  and  Dumb  Children.1 — They 
should  be  treated  as  much  like  normal  children  as  pos- 
sible, and  encouraged  to  play  with  other  children  and 
with  all  sorts  of  toys.  Thev  should  be  talked  to  by  the 
parents  or  other  people  as  much  as  possible,  for  a  little  child 
who  does  not  hear  may  in  this  way  learn  that  there  is  a 
means  of  communication,  and  will  understand  better  when  it 
is  taught  lip  reading.  When  possible  a  child  should  be 
taught  a  sign  language,  the  manual  alphabet,  articulation, 
and  lip  reading. 

Touch. — This  is  well  developed  at  birth  in  the  lips  and 
tongue.  After  the  third  month  it  is  noted  that  the  surface 
of  the  entire  body  is  sensitive  to  touch.  Pain-sense  is  not  so 
well  matured  as  it  is  later  in  life.  Temperature-sense  is 
present  very  early. 

Taste. — This  is  well  manifested  at  birth. 

Smell. — This  probably  develops  last  of  all. 

Speech. — Children  differ  greatly  in  the  time  at  which  they 
begin  to  talk.  Girls  usually  commence  a  month  or  two  be- 
fore boys.  Words  are  spoken  at  the  end  of  the  first  year, 
and  short  sentences  by  the  end  of  the  second.     After  the  sec- 

1  Drummond,  Pediatric.?,  December  15,  1901,  p.  440. 


28  DISEASES  OF  INFANTS  AND   CHILDREN 

ond  year  dumbness  should  suggest  mental  deficiency.  It 
should  be  remembered  that  some  children  talk  late  without 
any  apparent  cause.  Examine  the  hearing  and  for  tongue- 
tie  in  all  these  cases. 

TEETH, 

Eruption  of  the  Milk   Teeth. 

1. — Two  lower  central  incisors 6  to    9  months. 

2. — Four  upper  incisors 8  to  12       " 

3. — Two  lower  lateral  incisors  and  four  anterior 

molars 12  to  15       " 

4. — Four  canines 18  to  24       " 

5. — Four  posterior  molars 24  to  30       " 

At  one  year  a  child  should  have 6  teeth. 

At  one  and  one-half  years  a  child  should  have  .....  12     " 

At  two  years  a  child  should  have 16     " 

At  two  and  one-half  years  a  child  should  have 20     " 

The  above  gives  the  average  according  to  Holt.  There 
are  wide  variations.  Some  children  are  born  with  teeth,  but 
these  are  usually  shed  early.  Others  may  not  cut  one  until 
the  end  of  the  first  year.  About  one-third  of  the  children 
cut  their  teeth  without  any  symptoms  whatever.  In  a  sec- 
ond third  there  are  slight  symptoms  of  discomfort  with  great 
nervousness  and  some  digestive  disturbances,  and  the  remain- 
ing third  usually  are  really  ill  each  time  a  tooth  is  coming 
through  the  gum.  There  may  be  attacks  of  gastro-intestinal 
disturbances,  such  as  indigestion,  vomiting,  and  diarrhoea  ; 
bronchitis  or  eczematous  eruptions,  which  disappear  promptly 
when  the  tooth  is  cut. 

Syphilitic  children  are  said  to  have  their  teeth  early,  and 
that  they  decay  rapidly. 

Late  dentition  is  usually  due  either  to  rickets  or  cretinism. 

Eruption  of  the  Permanent  Teeth. 

First  molars 6  years 

Incisors • 7  to    8 

Bicuspids 9  to  10      " 

Canines 12  to  14      " 

Second  molars 12  to  15      " 

Third  molars 17  to  25      " 


PECULIARITIES  OF  INFANCY  AND   CHILDHOOD.     29 

Mercurial  Teeth  (See  also  Hutchinson  Teeth). — The  per- 
manent teeth  may  be  of  a  bad  color,  dirty,  with  irregular 
and  pitted  surface.  The  incisors,  canines,  and  first  molar- 
arc  most  often  affected.  The  teeth  are  not  dwarfed,  as  in 
syphilis.  The  defect  may  be  due  to  the  administration  of 
mercury  and  also  to  other  causes. 

Anatomic  Peculiarities. — The  lachrymal  glands  are  not 
developed  until  three  or  four  months,  sometimes  earlier.  In- 
fants under  this  age  do  not  shed  tears.     If  a  child  has  shed 


Fig.  3.— Diagram  showing  the  temporary  teeth  :    o,  Central  incisors ;  b,  lateral 
incisors  ;  c,  canines  ;  d,  anterior  molars  ;  e,  posterior  molars  (J.  P.  C  Griffith). 

tears  and  ceases  to  do  so  during  a  severe  illness  the  return  of 
the  tears  may  be  regarded  as  a  sign  of  convalescence. 

The  salivary  glands  are  not  very  active,  and  the  mouth  is 
rather  dry  in  early  infancy.  The  parotid  gland  is  developed 
at  birth.  The  diastasic  action  is  not  seen  in  the  saliva  from 
the  sublingual  glands  until  the  end  of  the  second  month, 
and  is  not  very  active  until  the  end  of  the  first  year.  The 
diastasic  action  of  the  saliva  is  feeble  in  early  infancy.  The 
amylolytic  ferment  in  the  pancreatic  juice  is  also  said  to  be 
feeble  at  this  time. 

The  sweat  glands  are  not  active  until  after  the  first  week 
of  life.  Profuse  sweating,  especially  about  the  head,  nearly 
always  indicates  rickets. 

The  sebaceous  glands  are  active  before  and  after  birth.  The 
secretion  at  birth  is  called  vernix  caseosa.  After  birth  it  is 
liable  to  collect  on  the  scalp  (see  Seborrhea). 

The  breasts  of  babies  (both  sexes)  contain  a  secretion 
looking  like  colostrum  and  having  the  composition  of  adult 
milk.     This   increases  for  a  week  or  so  and,  if  undisturbed, 


30 


DISEASES  OF  INFANTS  AND   CHILDREN. 


usually  disappears  in  two  or  three  weeks.  There  is  great 
danger  of  infecting  the  breast  at  this  time,  and  abscesses  and 
mastitis  may  result  from  attempting  to  squeeze  out  the  milk. 


Fig.  4.— One-sided  mammary  development.     Note  the  "  adenoid  "  expression. 

The  breasts   should  be  kept   clean  and  left  alone.     In  girls 
when  the  breasts   begin  to  develop,  from  the  tenth  to  the 


Fig.  5.— Diagram  showing  the  permanent  teeth  :  a,  Central  incisors  ;  b,  lateral 
incisors  ;  c,  canines  ;  d,  first  bicuspids ;  e,  second  bicuspids ;  /,  first  molars  :  o,  sec- 
ond molars  ;  h,  third  molars  (J.  P.  C  Griffith). 

fifteenth  year,  one  or  both  breasts  may  become  enlarged  and 
tender.  This  is  often  unilateral.  If  let  alone  the  condition 
causes  no  trouble  beyond  the  inconvenience. 


PECULIARITIES  OF  INFANCY  AND   CHILDHOOD. 

The  testicles  usually  pass  clown  through  the  inguinal  canal 
during  the  ninth  month  of  intra-uterine  life.  This  may  be 
delayed,  and  they  may  be  in  the  inguinal  canal  or  in  the  ab- 
domen at  the  time  of  birth,  and  make  their  descent  during 
the  first  month  or  later.  They  may  remain  in  their  fetal 
position.  If  descent  takes  place  after  the  first  month  after 
birth  a  hernia  is  liable  to  occur  at  the  same  time. 

The  thymus  is  relatively  large  in  infants.1  It  increases  in 
size  until  the  end  of  the  second  year.  It  then  remain-  sta- 
tionary until  puberty,  when  atrophy  occur-. 

The  stomach  is  tubular  in  form  and  nearly  vertical  at  birth. 
During  the  first  year  the  position  becomes  more  horizontal. 

At  birth  the  stomach  holds  about  li  ounces. 

At  three  months  the  stomach  holds  about  4J  ounces. 

At  six  months  the  stomach  holds  about  6  ounces. 

At  twelve  mouths  the  stomach  holds  about  9  ounces. 

The  stomach  digestion  is  not  nearly  as  complete  in  infants 
as  in  later  life,  and  it  begins  to  empty  itself  shortly  after  a 
nursing,  and  in  breast-fed  children  the  stomach  is  empty  in 
from  one  to  one  and  one-half  hours  in  the  young,  and  in 
about  two  hours  in  later  infancy.  In  bottle-fed  babies  the 
time  is  half  an  hour  or  more  longer. 

The  intestines  are  relatively  longer  in  infancy  and  the 
muscles  are  weak.  This  accounts  for  the  frequency  of  con- 
stipation and  also  of  distention  of  the  abdomen  from  gases. 
The  sigmoid  flexure  is  larger  than  in  later  life. 

The  liver  is  relatively  larger  in  infancy,  and  at  birth  ex- 
tends 1  to  2  cm.  below  the  costal  margin. 

The  bladder  is  almost  entirely  an  abdominal  organ  in  in- 
fancy, owing  to  the  small  size  of  the  pelvis. 

The  Back.2 — The  child's  spine  is  supple  and  flexible,  and 
this  gradually  lessens  as  the  child  grows  older,  but  any  stiff- 

1  J.  M.  Brickdale,  "  Thvmns  Gland,  Observations  on,  in  Children," 
Lancet,  October  7,  1905,  p.  1029.  T.  G.Moorhead,  "  The  Thvmns  Gland. ' 
Practitioner  December,  1905,  p.  733.  Bovaird  and  Xicoll,  "Weights  of  Vis- 
cera in  Infancy  and  Childhood,  with  Special  Reference  to  the  Weight  of  the 
Thymus  Gland,"  Archives  of  Pediatrics,  Sentember,  1906,  p.  641. 

2  Owen,  "  On  Children's  Spines,  Healthy  and  Otherwise,"  Pediatrics, 
March  1.  1896. 


32 


DISEASES  OF  INFANTS  AND   CHILDREN 


ness  should  be  regarded  as  a  sign  of  disease.     In  a  sitting 
position  the  child's  back  forms  a  graceful  curve,  broken  only 


Fig.  6. — Normal  spine. 


bv  the   prominence  of  the  seventh   cervical  vertebra,  which 
should  not  be   mistaken  for  a  deformity.     Any  stiffness  or 


Fig.  7.— Normal  spine. 


straightness  of  the  lumbar  or  cervical  regions  is  as  pathogno- 
monic of  disease  as  an   angular  deformity  would  be  in  the 


PECULIARITIES  OF  INFANCY  AND   CHILDHOOD.     33 

dorsal  region.  Lateral  deviation  should  also  be  looked 
for.  The  child  faces  away  from  the  examiner,  who  holds 
the  hips  firmly  and  directs  the  child  t<>  look  at  him  firsl 
from  one  side  and  then  the  other.  Any  difficulty  in  rotation 
i-  very  easily  noted.  Tuberculosis  of  the  vertebrae  and  rick- 
ets are  the  most  frequent  causes  of  stiffness.  In  the  former 
there   were   pain,  stiffness,  and  deformity,  and   in   the   latter 


Fig.  8.— Funnel-shaped  chest. 

the  deformity  may  be  overcome  by  traction,  and  there   is 
little  or  no  pain. 

Deformities    of    the    Thorax.— In    the     infant    the    chest 
is  normally  more  or  less  barrel    shaped;    that   is,  the  an- 
teroposterior and   the    transverse   diameters   are   nearly  the 
same.      This    is    seen    in   later    childhood    in   emphysema, 
3 


34  DISEASES  OF  INFANTS  AND   CHILDREN. 

whooping-cough,  and  sometimes  in  bronchiectasis  and  pneu- 
mothorax. 

The  chest  is  contracted  or  flattened  when  there  is  obstruc- 
tion to  the  breathing,  as  in  adenoids,  chronic  stenosis  of  the 
larynx,  etc.,  and  it  may  be  seen  in  weak  sedentary  chil- 
dren. 

The  funnel-shaped  chest,  in  which  there  is  a  depression  of 
the  lower  part  of  the  sternum,  is  seen  in  rachitis,  and  it  may 
occur  as  a  congenital  deformity. 

The  pigeon  breast,  in  which  the  sternum  is  prominent  and 
the  sides  of  the  chest  depressed,  is  seen  in  rachitis,  in  stenosis 
of  the  upper  air-passages,  as  in  adenoids,  and  sometimes  in 
congenital  heart  disease. 

Harrison's  sulcus,  a  depression  of  the  ribs  about  the  level 
of  the  ensiform  cartilage,  is  frequently  seen  in  rachitis. 

Asymmetry  is  seen  in  rachitis  and  in  the  deformities  ac- 
companying or  following  pleural  effusion,  empyema,  pneumo- 
thorax, chronic  pleurisy,  tuberculosis,  and  diseases  of  the 
spine. 

PREMATURE  AND  DELICATE  INFANTS, 

Premature  and  small  delicate  children  require  especial 
care.  If  the  weight  is  below  4  lbs.,  or  the  length  below  9 
in.,  an  incubator  should  be  used  to  maintain  the  body  heat. 
If  this  is  not  possible,  wrap  the  body  in  cotton,  with  a  sep- 
arate piece  of  absorbent  cotton  in  place  of  a  napkin,  roll  in 
several  blankets,  and  place  in  a  basket  and  surround  it  with 
hot- water  bottles.  The  room  temperature  should  be  80°  F. 
The  absorbent  cotton  should  be  changed  when  soiled.  The 
body  should  be  rubbed  with  olive  oil  every  three  days.  No 
bathing  is  permissible.  If  placed  in  an  incubator,  the  tem- 
perature should  be  from  80°  to  85°  F.,  according  to  the  size 
and  strength  of  the  child.  Oxygen  is  useful  when  there  are 
attacks  of  asphyxia  or  cyanosis. 

Feeding". — If  possible,  the  child  should  take  the  food  from 
a  small  bottle  with  a  soft  nipple.  If  it  cannot  suck  it  may 
be  fed  with  a  spoon,  medicine  dropper,  or  by  gavage.  The 
Breck   feeder   is  most   useful   for  this   purpose.     The  food 


PECULIARITIES  OF  INFANCY  AND  CHILDHOOD.     35 

should  be  given  slowly  to  avoid  regurgitation.     The  quantity 
and  quality,  as  well  as  the  interval,  should  be  regulated   by 


Fig.  9. — Modified  Auvard  incubator. 


the  size   and  condition  of  the   infant.      From  2  dr.  to  J  oz. 
every  hour,  until  the  child  is  about  the  size  of  a   full-term 


Fig.  10.— Breck  feeder  for  premature  and  weak  infants. 

infant,  is  an  average  allowance.     With  great  care  and  ex- 
perience many  premature  children  may  be  saved.1 

1  Voorhees,  Archives  of  Pediatrics,  May,  1900. 


36  DISEASES  OF  INFANTS  AND   CHILDREN. 


THE  EXAMINATION  OF  SICK  CHILDREN. 

The  history  of  the  child  is  very  important,  and  should  in- 
clude the  family  history,  especially  with  reference  to  syphilis, 
tuberculosis,  and  nervous  diseases,  the  history  of  the  mother 
during  pregnancy,  and  the  nature  of  the  birth,  as  well  as  a 
consideration  of  the  hygienic  surroundings  of  the  child. 
Inquiry  should  especially  be  made  concerning  the  character 
of  the  food  and  feeding  from  birth,  the  condition  of  the 
teeth,  whether  or  not  the  child  walks  and  when  it  began,  the 
same  of  talking,  and  also  how  the  child  sleeps.  It  should  be 
ascertained  what  infectious  diseases  the  child  has  had,  whether 
it  has  ever  had  snuffles,  and  whether  it  has  ever  had  any  dis- 
eases of  the  ear.  It  is  well  to  find  out  to  what  symptoms  the 
mother  attaches  the  most  importance  and  why  she  has  sought 
advice.  The  child  should  be  carefully  observed  before  it  is 
touched.  If  the  child  is  shy,  it  should  be  ignored  at  first, 
and  the  conversation  directed  to  the  mother.  Friendly  rela- 
tions may  often  be  established  with  the  child  by  first  examin- 
ing its  toys.  Young  children  are  usually  more  docile  when 
in  their  mothers'  laps  than  on  the  bed.  The  examination 
should  be  as  thorough  and  of  the  same  nature  as  that  made 
in  adults,  but  one  should  learn  to  make  it  rapidly,  so  that  it 
may  be  completed  before  the  sick  child  becomes  tired  and 
fretful.  The  pulse  and  respiration  should  be  counted  first, 
if  possible,  during  sleep,  as  it  is  sure  to  be  disturbed  later  by 
the  examination.  In  fact,  much  of  the  examination  may  be 
made  with  the  child  asleep,  but,  if  it  is  aroused,  try  to  have 
the  mother  or  nurse  do  it,  or  at  least  try  to  have  the  child 
see  some  familiar  face  on  waking,  lest  it  become  frightened. 
As  much  of  the  examination  as  possible  should  be  made  with 
the  child  sitting  up,  as  most  young  children  resent  being 
placed  on  their  backs.  Perhaps  more  can  be  determined  by 
inspection  and  palpation  than  in  the  adult.  It  is  often  sur- 
prising how  much  can  be  learned  by  palpation.  The  pres- 
ence of  enlarged  lymph-nodes,  of  other  swelling,  of  tender 
points  or  places,  the  presence  of  rickets  and  other  deformities 


THE  EXAMINATION  OF  SICK  CHILDREN.  1)1 

of  the  bones,  the  presence  or  absence  of  bronchial  rales  and 
vocal  fremitus,  the  size  of  liver  and  spleen,  the  presence  of 
gas  in  the  intestines,  or  of  ascites,  the  condition  of  the  ab- 
dominal muscles,  whether  rigid  or  not,  as  well  as  the  condi- 
tion of  the  other  muscles. 

The   ears  and   throat    should  be   examined   last,  as  it   is 
usually  impossible  to  do  much  with  a  child  after  this  is  done. 


Fig.  11.— Facial  expression  in  pneumonia.    Note  the  herpes. 

They  should   not  be  omitted  from  the  examination,  as  they 
are  frequently  the  seat  of  disease. 

The  facial  expression  is  often  suggestive,  and  may  be 
pathognomonic.  If  the  child  is  feeling  well  it  generally  looks 
it,  and  if  not,  pain,  anxiety,  or  distress  will  be  depicted  in 
its  expression.  One  often  hears  the  remark  :  "  The  diagnosis 
must  be  very  difficult  with  infants,  as  they  cannot  tell  you 
anything."  My  invariable  reply  is :  "That  is  balanced  by 
the  fact  that  they  never  lie."  If  the  child  has  adenoids,  the 
expression  will  vary  with  the  amount  of  obstruction.  The 
month  is  usually  open,  the  nostrils  narrow  and  the  nose 
small,  and  the  general  expression  is  dull.  One  should  not 
forget  that  sometimes  the  obstruction  is  due  to  nasal  diseases. 


38  DISEASES  OF  INFANTS  AND   CHILDREN. 

In  meningitis  the  expression  is  staring,  there  is  often  squint 
and  inequality  of  the  pupils,  there  may  be  also  wrinkles  in 
the  face,  giving  it  the  appearance  of  an  adult  in  distress. 
There  is  often  retraction  of  the  head  and  a  bulging  fontanel. 
In  pneumonia  the  expression  is  anxious,  the  mouth  is  usually 
partly  open,  and  the  nostrils  dilated  and  moving  with  the 
respirations.  The  face  is  often  flushed.  In  diarrhea  or 
vomiting  the  expression  is  staring,  the  eyes  are  sunken  and 
there  are  hollows  under  the  eyes,  the  cheeks  may  also  be 
sunken.  In  nephritis  there  is  often  marked  puflmess  and 
edema  of  the  face,  with  its  characteristic  expression. 

The  anterior  fontanel  should  be  carefully  observed  as 
regards  the  size  and  tension.  It  often  closes  early  even  in 
normal  children,  and  always  very  early  in  microcephalus.  It 
is  usually  closed  by  the  eighteenth  month,  and  if  open  after 
the  second  year  it  may  be  regarded  as  abnormal.  The  delay 
in  closure  may  be  due  to  hydrocephalus,  rickets,  or  to  cretin- 
ism. The  fontanel  pulsates,  the  pulsation  increasing  when 
the  blood-pressure  within  the  head  is  raised,  and  decreasing 
or  ceasing  altogether  when  the  pressure  is  lowered.  A  sys- 
tolic murmur  may  occasionally  be  heard  over  the  fontanel, 
but  apparently  this  has  no  diagnostic  significance.  The  ten- 
sion of  the  fontanel  is  very  important.  It  is  increased  in 
cerebral  hyperemia,  which  occurs  in  most  acute  fevers.  It  is 
increased  on  crying  and  on  coughing.  Bulging  of  the  fontanel 
may  be  seen  in  meningitis  and  in  brain  tumor.  Depression 
of  the  fontanel  is  noted  when  there  is  lowering  of  the  blood- 
pressure  in  weakened  conditions,  and  is  noted  in  loss  of  fluid 
from  the  body,  as  in  severe  diarrheas.  With  meningeal 
symptoms  in  the  course  of  the  diarrhea  the  depression  is  a 
valuable  indication  that  the  meninges  are  probably  not  in- 
volved. In  the  same  way  a  normal  tension  with  meningeal 
or  cerebral  symptoms  is  of  great  value  in  making  differential 
diagnosis  between  meningitis  and  pneumonia,  or  diarrhea 
with  meningeal  symptoms. 

Craniotabes. — The  thinning  out  of  the  bones  of  the 
skull  in  spots,  so  that  they  are  no  thicker  than  parchment,  is 


THE  EXAMINATION  OF  SICK  CHILDREN.  39 

seen  in  early  rickets  and  congenital  syphilis.  The  same 
thinning  is  seen  in  premature  infants  along  the  sutures.  The 
sensation  to  the  finger  is  that  of  pressing  in  a  derby  hat  and 
allowing  it  to  reshape  itself. 

The  pupils  contract  from  light  and  after  a  few  months 
on  accommodation.  Contracted  pupils  are  noted  in  sleep, 
after  the  administration  of  opiates,  and  sometimes  in  menin- 
gitis, especially  in  the  early  stages.  Dilated  pupils  are  noted 
just  before  death  in  severe  auto-intoxication,  especially  that 
from  the  intestinal  tract,  and  often  in  meningitis. 

Inequality  of  the  pupils  may  be  seen  in  meningitis  and 
other  serious  brain  diseases,  as  well  as  in  diseases  of  the 
sympathetic  nervous  system.  Hippus,  or  rhythmic  contrac- 
tion and  dilatation  of  the  pupils,  may  be  noted  in  nodding 
spasm  and  in  some  other  diseases. 

Strabismus. — This  is  a  puzzling  symptom  and  requires 
especial  study,  for  which  the  student  is  referred  to  the  text- 
books on  diseases  of  the  eye. 

The  squint  may  be  due  to  paralysis  of  the  eye  muscles,  as 
after  diphtheria,  or,  in  the  course  of  meningitis  or  brain 
tumor,  it  may  be  due  to  errors  of  refraction,  and  it  is  often 
due  to  a  disturbance  of  the  coordination  of  the  muscles,  as  in 
high  fever. 

Amaurosis. — Blindness  without  apparent  eye  disease  is 
met  with  in  some  forms  of  idiocy  and  sometimes  after  men- 
ingitis and  in  chronic  hydrocephalus,  after  some  infectious 
diseases,  as  whooping-cough,  and  in  uremia.  Congenital  word 
blindness  may  occasionally  be  noted  in  school  children. 

Ophthalmoscopic  examination  may  be  useful  in 
meningitis,  brain  tumor,  amaurotic  family  idiocy,  and  diseases 
of  the  eye.  The  indirect  method  is  most  useful.  In  infancy 
the  pigment  of  the  choroid  is  arranged  irregularly  and  should 
not  be  mistaken  for  diseases  of  the  eye. 

Nystagmus  is  seen  with  nodding  spasm,  sometimes  in 
tuberculous  meningitis,  and  in  brain  tumor  or  other  nervous 
affections.  It  may  also  be  present  in  diseases  of  the  eye,  as 
in  choroiditis. 


40  DISEASES  OF  INFANTS  AND   CHILDREN. 

The  ears1  should  be  examined,  and  this  may  usually  be 
done  without  a  speculum,  owing  to  the  short  meatus.  Otitis 
is  a  frequent  cause  of  fever,  and  is  usually  overlooked  until 
rupture  of  the  drum  occurs. 

Deafness. — This  is  usually  the  result  of  middle-ear  dis- 
ease or  adenoids,  but  may  follow  various  infection,  such  as 
cerebrospinal  fever,  whooping-cough,  and  mumps.  It  is  fre- 
quently seen  in  late  cases  of  congenital  syphilis,  and  forms 
one  of  Hutchinson's  triad  of  signs  of  congenital  syphilis. 

The  prognosis  depends  on  the  cause.  Adenoids  should  be 
removed  and  otitis  media  persistently  treated.  After  the  in- 
fections the  outlook  is  bad.  Deaf  children  should  be  talked 
to  as  much  as  possible,  and  efforts  made  to  teach  them  how 
to  read  the  lips.     (See  p.  354.) 

An  acute  nasal  discharge  suggests  coryza,  diphtheria, 
scarlet  fever,  or  influenza.  A  chronic  nasal  discharge  is  seen 
in  adenoids  and  congenital  syphilis. 

The  normal  child  sleeps  with  the  mouth  closed.  If  it  is 
open  in  acute  disease  it  usually  means  an  acute  coryza,  swell- 
ing in  the  throat,  as  in  diphtheria  or  scarlet  fever,  or  retro- 
pharyngeal abscess.  If  it  is  chronic  it  usually  indicates  the 
presence  of  adenoids. 

The  Palate. — High  arching  of  the  palate  is  frequently 
noted,  especially  after  the  development  of  the  second  teeth. 
Much  can  be  done  by  a  skilful  dentist  to  prevent  this.  It  is 
very  frequent  in  the  mentally  deficient. 

Epithelial  Pearls. — These  are  little  inclusions  of  the 
mucous  membrane  in  the  median  line  of  the  palate,  appear- 
ing as  little  white  or  yellow  bodies  about  the  size  of  a  pin's 
head.  They  are  most  frequently  seen  in  early  infancy  and 
sometimes  ulcerate,  leaving  small  oval  ulcers  which  heal  very 
slowly.     The  pearls  should  not  be  mistaken  for  any  disease. 

Perforation  is  nearly  always  due  to  syphilis. 

Sucking  Pads. — These  are  little  masses  of  fat  outside' 
the  buccinator  and  masseter  muscles  which  prevent  the  cheeks 

1  J.  F.  McKernon,  "Aural  Examination  in  Acute  Diseases  of  Children," 

Journal  of  the  American  Medical  Association,  January  7,  1905,  p.  23. 


THE  EXAMINATION  OF  SICK  CHILDREN.  41 

from  going  in  during  sucking.  They  are  especially  notice- 
able when  there  has  been  rapid  emaciation  in  children  under 
one  year  of  age,  occasionally  older  children,  and  are  best 
seen  when  the  child  cries. 

The  Sputum  is  coughed  up  and  swallowed  until  the  child 
is  five  or  six  years  old.  It  may  sometimes  be  obtained  bv 
swabbing  the  throat  immediately  after  coughing.  Hemopty- 
sis is  rare  in  children.  The  spitting  of  blood  is  usually  from 
the  throat  or  gums. 

The  cry  of  the  child  is  of  some  value.  Infants  cry 
from  many  causes  besides  pain.  The  more  delicate  the  child 
and  the  more  unstable  its  nervous  system  the  more  easily  it 
cries.  Cold  feet,  uncomfortable  clothes,  soiled  napkins, 
anger,  and  hunger  are  the  most  frequent  causes.  The  cry 
of  hunger  is  irregular  and  fretful,  and  ceases  when  the  child 
is  fed.  The  cry  of  indigestion  is  very  similar,  but  feeding 
aggravates,  rather  than  lessens,  the  crying,  except  for  a  few 
moments  after  taking  food.  The  cry  of  pain  is  a  sharp, 
piercing  cry.  Sharp,  piercing  screams — the  "  hydrocephalic 
cry  " — may  be  noted  in  chronic  hydrocephalus,  meningitis, 
idiocy,  mental  deterioration,  acute  otitis  media,  and  at  night 
in  early  hip-joint  disease.  General  or  local  tenderness  may 
cause  screaming,  as  in  handling  a  child  with  rickets,  scurvy, 
or  other  disease,  in  voiding  irritating  urine,  and  in  anal 
fissure. 

Pain. — Pain  lohich  is  localized  by  the  child  in  the  same 
place  should  always  be  regarded  seriously,  as  it  is  usually 
due  to  organic  disease. 

Pleuritic  pains  may  be  referred  to  the  median  line,  or  to 
the  epigastrium,  and  pleurisy  with  pneumonia  often  causes 
pain  and  rigidity  in  the  abdomen,  and  if  on  the  right  side  it 
may  be  mistaken  for  appendicitis. 

Abdominal  pain  is  usually  due  either  to  gastro-intestinal 
disorders,  in  young  infants  to  wind  colic,  to  caries  of  the 
spine,  to  appendicitis,  or  peritonitis. 

Pain  in  the  thigh  or  the  inner  side  of  the  knee  is  usually 
due  to  hip-joint  disease. 


42  DISEASES  OF  INFANTS  AND   CHILDREN. 

Pain  or  aches  on  both  sides  of  the  body  or  in  both  arms  or 
legs  should  always  lead  to  a  careful  examination  of  the  spine. 

Sleeplessness. — Disturbances  of  sleep  in  children,  as  a 
rule,  are  distinctly  abnormal.  They  may  be  due  to  many 
causes.  Any  disease  in  which  there  is  pain  or  itching  will 
produce  sleeplessness,  and  the  same  is  true  where  there  is 
cough,  dyspnea,  or  diarrhea.  Obstruction  to  breathing  through 
the  nose  is  another  very  important  cause,  and  this  most  fre- 
quently is  due  to  adenoids.  Fever  usually  produces  drowsi- 
ness, but  in  some  children  may  cause  wakefulness.  Nervous 
children  usually  sleep  badly.  Disturbed,  restless  sleep  is  one 
of  the  characteristics  of  rickets  and  often  of  congenital  syph- 
ilis.    Indigestion  is,  of  course,  a  very  important  cause. 

Some  children  normally  sleep  but  very  little,  apparently 
not  needing  so  much  sleep  as  the  average  child,  and  these 
children  are  a  source  of  considerable  worry.  Another  ne- 
glected cause  of  sleeplessness  are  the  noises  about  the  child. 
Under  ordinary  circumstances  these  seem  to  be  disregarded, 
but  certain  neurotic  children  are  very  much  disturbed  by 
unusual  or  unaccustomed  noises.  Sleeplessness  in  these  cases 
may  make  a  very  marked  difference  in  the  child's  health,  and 
these  children  usually  do  well  when  moved  to  a  quiet  place, 
and  frequently  their  health  again  becomes  poor  on  their  re- 
turn to  the  locality  in  which  they  get  insufficient  sleep. 
Sleeplessness  may  also  be  due  to  too  much  excitement,  es- 
pecially in  the  evening,  to  a  lack  of  ventilation,  and,  above 
all,  to  improper  training. 

The  lymph-nodes1  should  always  be  examined.  The 
cervical  are  the  most  frequently  enlarged,  the  most  frequent 
cause  being  inflammations  in  the  throat.  The  posterior  cer- 
vical nodes  are  enlarged  in  measles  and  German  measles, 
and  in  inflammations  of  the  scalp. 

The  position  of  the  child  should  always  be  noted.    It 
there  is  pain  in  the  abdomen  the  child  lies  on  its  back  with 
its  legs  drawn  up.     Opisthotonos  is  seen  in  meningitis  and 

1  Alfred  Friedlander,  "  Lymph-nodes,  Diagnosis  of  Enlaged,"  Journal 
of  the  American  Medical  Association,  January  7,  1905,  p.  19. 


THE  EXAMINATION  OF  SICK  CHILDREN.  43 

tetanus.  Retraction  of  the  head  is  seen  in  meningitis,  maras- 
mus, and  retropharyngeal  abscess. 

The  skin  should  be  examined  for  eruptions,  as  to  whether 
it  is  dry  or  moist,  and  whether  there  is  any  pigmentation  or 
cyanosis. 

Desquamation  of  the  skin  is  seen  in  many  skin  diseases, 
after  scarlet  fever  and  measles,  and  in  poorly-cared-for  chil- 
dren the  skin  usually  desquamates  after  a  few  baths. 

Tache  cerebrale  is  the  name  given  to  the  red  line  seen, 
in  some  conditions,  after  drawing  the  finger  or  a  blunt  instru- 
ment over  the  skin.  It  is  seen  in  meningitis  and  many 
febrile  and  nervous  conditions. 

Chills  or  Rigors.1 — Chill  in  a  child  is  usually  replaced 
by  a  convulsion,  but  occasionally  a  chill  may  be  noted,  or  if 
not  a  distinct  chill,  a  cyanosis  and  coldness  of  the  body  or  of 
some  part  of  it.  This  may  be  seen  in  malaria.  Thomson 
has  called  attention  to  the  fact  that  a  distinct  rigor  in  a  child 
under  two  practically  always  means  an  acute  pyelitis. 

Temperature.2 — There  are  certain  differences  in  the 
temperature  of  children  and  in  adults  which  are  well  to  bear 
in  mind.  The  first  is  that  the  child's  heat  center  is  not  as 
well  balanced  as  it  is  later  in  life,  and  smaller  things  may 
cause  considerable  variations  in  temperature.  In  premature 
children  and  very  young  children,  and  perhaps  to  a  lesser 
extent  in  small  children,  the  temperature  is  usually  influenced 
by  external  heat  and  cold.  The  temperature  may  be  sub- 
normal after  long  periods,  due  to  insufficient  warmth  and 
clothing,  and  this  usually  has  a  very  detrimental  effect  on  the 
child's  nutrition.  On  the  other  hand,  the  temperature  of 
such  children  may  be  raised  and  even  pyrexia  caused  by 
having  hot-water  bottles  about  the  child.  I  have  been  con- 
sulted on  a  number  of  occasions  to  explain  fever  in  prema- 
ture children  that  were  being  raised  in  home-made  incubators ; 
an  explanation  was  found  in  the  use  of  too  much  heat. 

1  Baldwin,  "Rigors  in  Children,"  Lancet,  June  13,  1896,  p.  1635. 

2  "  Temperature,  Pulse,  and  Eespiration  in  Infancy  and  Childhood," 
Archives  of  Pediatrics,  December,  1905,  p.  909. 


44 


DISEASES  OF  INFANTS  AND   CHILDREN. 


The  temperature  will  vary  according  to  the  method  used 
in  taking  it.  The  best  temperatures  are  those  taken  in  the 
rectum,  and  the  thermometer  should  be  left  in  until  it  ceases 
to  rise,  quite  regardless  of  whether  it  is  a  half-minute  or  a 
three-minute  thermometer.  The  temperatures  taken  in  the 
axilla  or  groin  are  usually  from  0.5°  to  1.5°  F.  in  well 
children,  and  0.5°  to  2°  F.  in  sick  children.  Sometimes 
the  difference  is  not  marked,  particularly  in  temperatures 
taken  in  the  groin,  but  at  other  times  it  may  be.  I  have 
given  up  the  use  of  axillary  and  groin  temperatures  entirely 
and  depend  upon  the  rectal  temperatures  in  young  children, 
and  after  four  years  of  age,  either  on  that  taken  in  the  rec- 


|SjUXhW> 

OL.Wl.                            HaW\_                                 P.1M.. 

\oa°  .5 

f* 

\ 

V 

!w 

\ 

y 

1 

Vj 

/ 

^ 

Fig.  12.— Normal  daily  range  of  temperature  in  children.    (After  Finlayson,  Glas- 
gow Medical  Journal,  February,  1869,  page  186.) 

turn  or  in  the  mouth.  It  is  well  to  have  colored  thermome- 
ters for  rectal  use  and  plain  white  ones  to  be  used  in  the 
mouth.  The  temperature  will  also  be  found  to  vary  slightly 
with  the  extent  that  the  thermometer  is  placed  in  the  rectum, 
but  this  is  usually  but  a  trifling  difference. 

The  daily  range  in  the  temperature,  even  in  healthy  chil- 
dren, is  much  greater  than  it  is  in  adults.  In  some  children 
it  may  vary  from  2°  to  3°  F.,  while  in  others  it  may  only 
be  1°  F.  In  infants  and  young  children  the  temperature  is 
highest  during  the  day,  from  the  time  the  child  wakes  until 
evening.  In  the  early  evening  the  temperature  starts  to  fall, 
and  may  drop  from  1  to  3  degrees  either  before  or  after  the 


THE  EXAMINATION  OF  SICK  CHILDREN.  45 

child  goes  to  sleep.  This  low  temperature  continues  until 
about  2  or  3  o'clock  in  the  morning,  when  there  is  a  gradual 
rise  until  about  the  rising  time.  The  fall  in  the  evening 
is  most  marked  between  7  and  9  o'clock.  It  may  begin 
as  early  as  5  o'clock,  and  there  is  considerable  variation 
in  different  children,  depending  upon  external  circum- 
stances and  the  child's  individual  peculiarities.  A  rise 
of  temperature  in  the  evening  in  a  child  is  always  sig- 
nificant, and  if  there  is  nothing  else  to  account  for  it, 
and  it  recurs  day  after  day,  one  should  think  of  tuberculosis 
or  typhoid  fever,  although  there  may  be  innumerable 
other  causes.  Persistent  high  temperature1  is  seen  in  quite  a 
number  of  different  diseases — tuberculosis,  typhoid,  bron- 
chial pneumonia,  infections  of  the  urinary  tract,  diseases  of 
the  bones  and  joints  being  the  most  frequent  examples.  One 
occasionally  meets  with  a  child  who  apparently  has  some 
disturbance  of  the  heat  center;  such  children  apparently  have 
perfect  health  and  have  normally  a  high  temperature.  I 
have  seen  one  or  two  examples  of  persistent  temperature  of 
100°  or  101°  F.,  which  continued  for  years  without  any  ap- 
parent disturbance  of  the  child's  health.  On  the  other  hand, 
one  frequently  sees  children  who  normally  seem  to  have  low 
temperature.  These  children  usually  have  a  poor  peripheral 
circulation,  suffer  with  cold  hands  and  feet,  and  complain  a 
great  deal  in  cold  weather,  and  usually  suffer  from  changes 
in  the  temperature.  Some  of  these  children  suggest  a  pos- 
sibility of  disturbance  of  the  internal  secretions,  and  which 
in  turn  might  of  course  affect  the  heat  center.  A  sudden 
high  temperature  in  a  child  is  most  frequently  due  to  indi- 
gestion or  some  disturbance  of  the  stomach  or  intestines.  It 
is  seen  also  in  the  onset  of  the  exanthems,  especially  scarlet 
fever.  It  is  frequently  seen  in  the  onset  of  influenza  and  in 
pneumonia.  Hyperpyrexia2  is  most  frequently  due  to  dis- 
ease of  the  stomach  and  bowel,  particularly  in  certain 
forms   of  summer   diarrhea.      It   may  also   be   noted    from 

1  Bovaird,  Jr.,  "  The  Differentiation    of  Common  Types  of  Protracted 
Fever,"  American  Journal  of  Medical  Sciences,  vol.  cxxxvii,  1909,  p.  49. 

2  Longwell,   "  Hyperpyrexia,"   Scottish   Medical   and  Surgical  Journal, 
January,  1899,  p.  39. 


46  DISEASES  OF  INFANTS  AND  CHILDREN 

the  external  application  of  heat  in  a  premature  child,  as  noted 
above. 

The  pulse l  varies  greatly  in  infants.  It  may  be  rapid  and 
even  irregular  from  slight  causes.  The  regularity  and 
volume  are  of  greater  importance  than  the  pulse  rate.  A 
slow,  irregular  pulse  suggests  meningitis,  and  also  occurs  in 
brain  tumor. 

The  respiration  may  be  rapid  and  irregular  from  slight 
causes  while  the  child  is  awake.  It  is  frequently  irregular 
during  sleep  in  meningitis.  Dypsnea  is  present  in  all  severe 
diseases  of  the  lungs  and  pleura — as  in  pneumonia,  severe 
bronchitis,  and  empyema,  It  causes  rapid  respiration  with 
sinking  in  of  the  supraclavicular,  suprasternal,  and  inter- 
costal spaces. 

Pleural  effusions2  are  frequently  called  pneumonia  on 
account  of  the  presence  of  bronchial  breathing.  A  pleural  effu- 
sion in  a  child  under  three  years  is  nearly  always  purulent. 

Palpation  of  the  Abdomen. — If  the  abdomen  is  rigid 
and  it  is  not  advisable  to  give  an  anesthetic,  the  child  should  be 
immersed  in  a  bath-tub  in  hot  water.  After  five  or  ten  minutes 
it  will  be  found  that  in  many  cases  the  abdomen  will  be  suffi- 
ciently relaxed  to  permit  of  a  fairly  satisfactory  examination. 

I/umbar  puncture  is  of  value  in  making  a  diagnosis  of 
meningitis.  If  properly  done  it  is  perfectly  harmless.  (For 
procedure,  see  Cerebrospinal  Fever.) 

The  muscles  of  the  young  child  contract  very  easily,  and 
may  often  be  in  a  state  of  partial  or  even  complete  contrac- 
tion. Too  much  stress  should  not  be  placed  upon  rigidity 
of  the  neck  or  other  muscles,  as  trifling  often  unexplained 
causes  may  be  responsible. 

Myatonia. — A  condition  of  general  muscular  weakness. 
There  is  a  congenital  form  (myatonia  congenita,  Oppenheim)3 
in  which  there  is  pseudoparalysis  with  loss  of  deep  reflexes 
and  lessened  electrical  reactions.     Lesser  degrees  of  myatonia 

1  Nicholson,  "The  Pulse  in  Infancy,"  Scottish  Medical  and  Surgical  Jour- 
nal, May,  1901,  p.  419. 

2  G.  S.  Middleton,  "  Pleural  Effusion  and  Empyema  in  Children,  Diagno- 
sis of,"  Practitioner,  November,  1906,  p.  602. 

3  Haberman,  The  American  Journal  of  the  Medical  Sciences,  March,  1910, 
p.  383. 


THE  EXAMINATION  OF  SICK  CHILDREN.  47 

are  seen  in  rickets,  congenital  syphilis,  in  marasmus,  Mon- 
golian idiocy,  and  in  advanced  stages  of  the  myopathies. 

Edema  if  general  and  marked  is  usually  from  nephritis. 
It  may  result  in  the  more  dependent  parts  from  heart  or 
liver  disease  or  any  obstruction  to  the  circulation.  Edema 
of  the  eyelids  may  be  seen  in  urticaria  and  in  whooping- 
cough.     Edema  may  be  .-ecu  in  severe  anemia-. 

General  edema  may  occur  as  a  complication  of  marasmus, 
independent  of  any  disease  of  the  heart  or  kidneys.  The 
edema  may  come  on  suddenly  or  gradually  and  may  be  slight  or 
severe.  It  may  disappear  and  reappear.  It  is  evidently  due  to 
the  hydremia  and  weakened  blood-vessels.  It  is  most  frequent 
under  six  months  of  age,  but  may  be  seen  in  older  children. 

Acute  Circumscribed  Edema.1 — Angioneurotic  edema,  or  giant 
urticaria,  may  affect  infants  and  children,  causing  an  acute 
swelling  of  almost  any  part  of  the  body,  usually  the  skin,  but 
sometimes  the  mucous  membranes,  joints,  or  muscles.  It 
may  cause  puzzling  symptoms  if  it  affects  stomach,  intestines, 
or  the  srenito-urinary  tract.  In  the  larynx  it  mav  be  a  source 
of  great  danger. 

Edema  of  the  Face. — Edema  may  be  caused  by  a  great 
variety  of  things,  chief  of  which  are  acute  or  chronic  nephri- 
tis ;  and  in  all  cases  of  edema  the  urine  should  be  carefully 
investigated.  The  swelling  almost  always  begins  about  the 
eyes  and  forehead,  and  practically  one  rarely  sees  edema  due 
to  nephritis  that  does  not  affect  these  parts.  It  may  also  be 
due  to  edema  in  the  course  of  anemia,  and  to  food  poisoning 
in  which  the  edema  has  the  manifestations  of  urticaria. 
Swelling  of  the  face  may  also  be  seen  in  children  who  have 
been  exposed  to  cold  winds,  and  in  these  cases  it  is  usually, 
if  not  always,  accompanied  by  small,  round,  hard,  bluish 
patches  which  may  give  rise  to  considerable  alarm  the  first 
time  they  are  seen.  Angioneurotic  edema  may  also  affect 
the  face.  The  swelling  may  be  due  to  insect  stings.  It  is 
usually  more  or  less  localized  and  frequently  there  is  a  his- 
tory of  being  stung.  The  skin  is  reddened  and  the  central 
puncture  may  often  be  made  out.     The  swelling  may  be  due 

1  Smith  and  Meara,  "  Edema,  Acute  Circumscribed,"  Archives  of  Pedi- 
atrics, May,  1906,  p.  361. 


48  DISEASES  OF  INFANTS  AND   CHILDREN. 

also  to  inflammation,  abscesses  about  the  teeth  being  the  most 
frequent  form.  The  obstruction  to  the  veins  in  the  thorax 
may  cause  edema  and  cyanosis  of  the  face,  and  may  be  due 
to  enlarged  thymus,  enlarged  lymphatics,  or  to  new  growth-. 

The  Hands. — Changes  in  the  hands  are  important,  as 
the  hands  are  always  visible. 

Clubbing  of  fingers,  usually  with  cyanosis  and  changes  in 
the  nails,  is  seen  in  congenital  heart  disease,  in  chronic  sup- 
purative diseases  of  the  chest,  as  empyema  and  bronchiectasis, 
in  tuberculosis  of  the  lungs  or  pleurisy,  or  in  chronic  pleu- 
risy or  pericarditis  with  adhesions.  It  is  said  to  occur  in 
cirrhosis  of  the  liver. 

The  shape  of  the  hand  is  characteristic  in  achondroplasia, 
the  little  finger  is  curved  in  Mongolian  idiocy.  In  rickets 
the  phalanges  may  be  larger  than  the  joints,  causing  a 
beaded  appearance.  Marked  deformities  are  caused  by 
arthritis  deformans,  and  a  dactylitis  or  inflammation  of  the 
fingers  may  result  from  either  syphilis  or  tuberculosis.  The 
#-ray  may  aid  in  differentiating  these.  In  syphilis  there  is  a 
gummatous  periostitis,  the  interior  of  the  bone  being  un- 
affected or  sclerosed,  while  in  tuberculosis  there  is  a  carious 
interior,  the  periostitis  being  secondary. 

There  may  be  characteristic  movements,  as  in  chorea  and 
athetosis.  Nervousness  may  also  be  revealed  by  clenched 
fists  or  movements.  The  presence  of  edema  or  cyanosis  is 
easily  seen,  and  the  habits  of  sucking  thumbs  or  fingers  and 
biting  the  nails  leave  their  traces. 

Examination  of  Stools. — The  length  of  time  the  food 
takes  to  pass  through  the  bowel  may  be  easily  determined  by 
marking  any  given  meal  by  administering  a  teaspoonful  of 
charcoal  and  noting  when  this  is  passed.  It  is  highly  im- 
portant for  the  physician  to  examine  the  stool  himself,  for, 
as  a  rule,  the  nurse  and  attendants  are  not  competent  to  de- 
scribe them  satisfactorily  and,  indeed,  many  physicians  are 
lacking  in  knowledge  on  this  point. 

Mucus  is  frequently  present  in  the  stools  of  infants  and 
young  children,  and  is  seen  in  diarrheas  of  all  sorts.  If 
there  are  shreds  and  strips  of  mucous  membrane,  mem- 
branous colitis  should  be  thought  of.     Large  quantities  are 


THE  EXAMINATION  OF  SICK  CHILDREN.  49 

seen  in  mucous  colitis  of  the  nervous  type,  which  i.*    how- 
ever, rare  in  children. 

Blood  in  the  stools  may  be  due  to  bleeding  fr<  m  anal 
fissures,  in  which  ease  the  hard  fecal  massses  are  streaked 
with  blood.  Apart  from  this,  small  patches  of  bright  red 
blood  in  otherwise  more  or  less  normal  stools  should  sueeesi 
polypus  of  the  rectum,  and  an  examination  should  be  made 
for  it.  Blood  mixed  with  mucus  is  frequently  noted  in  coli- 
tis, enterocolitis,  and  ulcer  of  the  bowel. 

The  stools  should  also  be  examined  for  parasites  of  various 
kinds  (see  Intestinal  Parasites  and  Hook-worm  Diseasej. 

If  the  flow  of  bile  is  interfered  with,  there  wdl  be  white 
stools  with  a  soft  consistency  and  an  offensive  odor.  See  also 
page  106  for  further  points  on  the  examination  of  the  stools. 

Sudden  Death. — This  is  not  uncommon  in  infants,  and 
may  occur  in  those  previously  healthy,  but  usually  is  seen  in 
children,  especially  in  asylums.  It  may  lead  to  unjust  suspicion 
as  regards  attendants.   The  more  common  causes  are  as  follows: 

1.  Malformations  of  internal  organs  which  may  have  es- 
caped attention.     This  usually  occurs  in  the  first  few  days. 

2.  Internal  hemorrhage.  This  is  usually  during  the  first 
or  second  week. 

3.  Asphyxia. 

a.  From  overlying. 

b.  To  the  aspiration  of  regurgitated  food. 

In  older  infants  the  asphyxia  may  be  due  to  rupture  of  a 
retropharyngeal  or  mediastinal  abscess,  or  from  pressure  of 
an  abscess  or  enlarged  lymph-nodes  on  the  pneumogastric 
nerve,  or  from  sudden  dislocation  of  the  cervical  vertebra  in 
a  course  of  caries  of  the  spine. 

4.  Marasmus,  apparently  from  heart  failure.  These  chil- 
dren are  often  found  dead  in  the  morning,  and  there  is  uot 
infrequently  more  or  less  atelectasis. 

5.  Enlarged  thymus.  Children  with  lymphatism  are  liable 
to  die  from  slight  accidents,  the  administration  of  anesthetics 
during  a  convulsion,  or  during  slight  or  severe  illness. 

6.  Convulsions  without  reference  to  their  cause. 

7.  In  high  temperature  after  a  few  hours'  illness,  seen  in 
the  course  of  acute  infections,  toxemias,  and  heat-stroke. 

4 


50 


DISEASES  OF  INFANTS  AND   CHILDREN. 


DISEASES  OF  THE  NEWBORN. 


Intra-uterine. 

Due  to  any  disturbance  of 
the  placental  circulation 
during  labor. 


ASPHYXIA. 

This  may  be  intra-  or  extra-uterine,  and  the  causes  are 
given  in  the  following  table  : 

f  Hemorrhage, 
j    Convulsions, 
f  Mother,     -j    Use  of  ergot  in  second  stage. 
I    Prolonged  second  stage. 
[_  Death  of  mother. 
Pressure  on  cord. 
Twisting  of  cord. 
Pressure  on  brain. 
Child.        -|   Early  separation  of  placenta. 
Entrance    of    mucus,    blood, 
amniotic  fluid,  or  meconium 
into  air-passages. 
Malformations    of    brain,    circulatory,    or    respiratory 
organs. 
Extra-uterine.       .   Intra-uterine  disease  of  brain,  circulatory,  or  respiratory 
(Bare.)  '       organs. 

Injury  of  brain,  circulatory,  or  respiratory  organs. 
In  premature  infants  from  weakness. 

I/esions. — There  are  congestion  and  punctate  hemorrhages 
of  the  viscera,  aspirated  material  in  the  air-passages,  and  if 
the  child  has  breathed  or  has  been  forcibly  inflated  there 
may  be  emphysema.  In  the  extra-uterine  form,  malforma- 
tion, disease,  or  injuries  may  be  found. 

Symptoms. — Two  forms  may  be  described,  between 
which  there  are  all  grades  : 


Asphyxia  Livida. 

Cyanosis. 

Vessels  of  cord  full  and  firm. 

Pulse  full,  slow,  and  strong. 


Muscle  tone  good. 
Responds  to  external  stimuli. 
Symptoms  disappear  with  beginning 

respiration. 
Prognosis  good. 
Recovery  usually  prompt. 


Asphyxia  Pallida. 

Pallor  (lips  may  be  blue). 

Vessels  of  cord  almost  empty  and 
relaxed. 

Pulse  absent  or  nearly  so.  It  may 
be  impossible  to  make  out  heart- 
beat. 

Muscle  tone  poor,  child  relaxed. 

Does  not  respond  to  stimuli. 

Symptoms  are  liable  to  persist. 

Prognosis  bad. 

Recovery  slow ;  symptoms  liable  to 
recur  and  child  may  die  even 
after  several  days  have  elapsed. 


DISEASES  OF  THE  NEWBORN. 


51 


Diagnosis. — Cerebral  compression  from  hemorrhage 
may  present  similar  symptoms  and  may  be  associated  with 
asphyxia.  There  is  usually  the  history  of  compression  from 
a  long  labor  or  from  instrumental  delivery.  The  fontanel 
bulges,  there  is  coma,  and  often  paralysis. 

Anemia  from  a  large  hemorrhage,  as  from  cord  rupture, 
may  resemble  asphyxia  pallida. 

Prognosis. — This  depends  upon  the  grade  of  the  condi- 
tion, and  to  a  slight  extent  upon  the  skill  with  which  the  child 


Fig.  13. 


?chultze's  method  of  artificial  respiration  :  A,  Inspiration  ;  B,  expiration 

(Hirst). 


is  treated.  Attempts  at  resuscitation  are  apt  to  be  abandoned 
too  early. 

Treatment. — Full  accounts  of  the  various  methods  of 
treatment  will  be  found  in  the  text-books  on  obstetrics. 

Clean  out  the  mouth  and  pharynx  with  the  finger  swathed 
in  absorbent  cotton.  Stimulate  respiration  by  spanking, 
alternate  hot  and  cold  baths  or  douches,  by  swinging  in  the 
air,  and  other  means.  If  very  livid,  allow  half  an  ounce  of 
blood  to  flow  from  the  umbilical  cord.  If  it  is  thought  that 
the  bronchial  tubes  contain  amniotic  fluid  or  mucus,  insert  a 


52  DISEASES  OF  INFANTS  AND   CHILDREN. 

small  soft-rubber  catheter  and  try  to  remove  it  by  suction. 
Laborde's  method  of  resuscitation  may  then  be  tried.  This 
consists  in  placing  the  child,  wrapped  in  a  blanket,  on  a 
chair  or  table,  so  that  the  head  hangs  over  the  edge.  Trac- 
tion is  then  made  on  the  tongue,  pulling  it  out  as  far  as  pos- 
sible and  then  letting  it  recede  at  the  rate  of  about  fifteen 
times  a  minute.  This  often  starts  the  respiration  by  irri- 
tating the  superior  laryngeal,  glossopharyngeal,  and  lingual 
nerves,  which  in  turn  affects  the  phrenic  nerve,  causing  con- 
traction of  the  diaphragm  and  intercostal  muscles.  This  is 
one  of  the  best  methods  of  resuscitation  ;  if  it  does  not  suc- 
ceed, artificial  respiration  must  be  tried.  Schultze's  method 
is  most  efficient.  Grasp  the  child  with  the  thumbs  on  the 
chest,  the  index-fingers  in  the  axilla?,  and  the  remaining 
fingers  supporting  the  back.  The  child  is  held  feet  down- 
ward, face  forward,  between  the  physician's  legs.  The  child 
is  then  swung  upward  until  the  physician's  arms  are  about 
horizontal ;  the  sudden  stopping  causes  the  child's  body  to 
double  up,  and  expiration  is  produced.  The  inspiration  is 
caused  by  the  return  to  the  original  position.  This  should 
not  be  done  too  rapidly.  This  may  be  too  severe  for  very 
weak  infants,  and  other  methods  may  be  substituted.  Inhala- 
tions of  oxygen  are  sometimes  of  great  service. 

The  lungs  may  be  inflated  artificially  by  the  mouth-to- 
mouth  method,  by  using  a  catheter  in  the  larynx,  or  by 
Ribemont's  inflator.     Too  much  force  should  not  be  used. 


CONGENITAL  ATELECTASIS. 

At  birth  the  lungs  are  solid,  but  are  rapidly  expanded  as 
soon  as  the  child  is  born.  This  process  of  expansion  is 
gradual,  and  may  take  one  or  two  days  or  more  before  it  is 
complete.  It  may  be  irregular,  and  areas  of  solid  lung  may 
remain,  especially  in  the  case  of  weak  children.  The  lower 
part  of  the  lungs,  in  the  back,  are  said  to  be  the  last  to  ex- 
pand. Where  this  fetal  condition  of  the  lungs  persists  it  is 
called  atelectasis. 

Pathology. — The  lung  is  only  partly  expanded,  usually 


DISEASES  OF  THE  NEWBORN.  53 

the  anterior  part  or  in  spots.  These  spots  are  generally  em- 
physematous. Only  one-quarter  or  one-third  of  the  lung 
may  be  dilated  ;  the  older  the  child  the  more  expanded  lung  it 
is  apt  to  have.  Marked  atelectasis  may  be  found  as  late  as 
three  months  where  it  was  not  suspected.  There  may  be 
evidences  of  pneumonia,  and  it  may  take  a  microscopic  ex- 
amination to  decide  whether  there  is  hypostatic  pneumonia 
or  atelectasis,  or  both.     The  spleen  is  usually  enlarged. 

Symptoms. — The  child  may  be  asphyxiated  at  birth 
and  only  recover  partly,  dying  after  one  or  more  relapses. 
The  asphyxia  may  be  apparently  recovered  from  and  not 
recur,  but  the  child  may  never  seem  to  thrive.  The  tem- 
perature of  the  body  is  low,  the  child  feeble,  and  more  or 
less  cyanosed.  The  infant  becomes  weaker  and  weaker,  and 
may  die  without  any  assignable  cause. 

Diagnosis. — This  may  be  difficult.  Symptoms  and  his- 
tory are  to  be  relied  on  more  than  physical  signs,  which  may 
be  wanting.  The  percussion  note  may  be  resonant  over  the 
entire  chest,  even  when  there  is  considerable  solid  lung, 
owing  to  the  fact  that  the  solid  lung  is  surrounded  with  em- 
physematous lung.  In  other  instances  the  areas  of  dulness 
are  distinct,  and  over  them  there  is  absence  or  diminution  of 
breath  sounds.     There  may  or  may  not  be  rales. 

Treatment. — Full  inflation  of  the  lungs  should  be  se- 
cured by  seeing  that  the  infant  either  cries  or  takes  full, 
long,  deep  breaths.  If  the  child  is  feeble,  it  should  be  made 
to  cry  at  least  once  a  day,  if  it  does  not  do  so  of  its  own 
accord.  Spanking,  frictions,  and  alternate  hot  and  cold 
douches  may  be  used  to  this  end.  The  child  should  be  kept 
warm.  It  should  be  taken  up  and  carried  about  and  fed  on 
the  nurse's  lap,  never  in  the  crib. 

ICTERUS. 
1.  Physiologic. — This  occurs  in  about  one-third  of  all 
children  born.  Eunge  places  it  as  high  as  80  per  cent.  It 
comes  on  during  the  first  week,  usually  from  the  third  to 
the  sixth  day.  It  increases  for  a  day  or  two  and  then  dis- 
appears, taking  a  week  or  two   to  clear  up  entirely.     The 


54  DISEASES  OF  INFANTS  AND   CHILDREN. 

urine  is  not  usually  bile  colored,  but  may  be.  The  stools 
are  normal.  Kehrer  states  that  it  is  more  frequent  in  the 
first  child.  It  does  not  affect  the  child  in  any  way,  but  it  is 
said  that  these  children  do  not  gain  as  rapidly  as  those  with- 
out it.  It  is  liable  to  be  more  intense  in  weak  children. 
There  are  numerous  theories,  the  most  plausible  being  that  it 
is  due  to  resorption  of  bile  and  of  destroyed  red  blood-cells 
in  the  liver. 

2.  From  Malformation  of  the  Bile  Ducts.1 — The 
bile  ducts  may  be  absent  or  impervious.  There  is  increasing 
jaundice  coming  on  after  birth.  The  urine  is  deeply  colored, 
and  the  stools  white.  The  liver  and  spleen  are  enlarged. 
Hemorrhages  under  the  skin  and  from  the  mucous  membranes 
are  common.  Vomiting  is  usually  absent.  Death  usually 
takes  place  within  three  months,  from  wasting  or  convul- 
sions. 

3.  Syphilitic  hepatitis  is  a  rare  cause  of  icterus  in  the 
newborn. 

4.  In  septic  infections  there  may  be  slight  icterus. 

ACUTE  INFECTIONS. 

Any  of  the  infectious  diseases  may  be  seen  in  the  newborn, 
especially  if  the  mother  has  the  disease  at  the  time  the  baby 
is  born.  There  is,  however,  a  natural  immunity  to  most  of 
the  infectious  diseases  of  childhood  during  the  first  few 
months  of  life.  The  symptoms  are  the  same  as  in  later  life. 
The  prognosis  is  bad,  owing  to  the  diminished  resistance  of 
early  life. 

PYOGENIC  DISEASES.2 

(Sepsis  of  the  Newborn ;  Puerperal  Fever  of  the  Newborn ; 
Septicemia ;  Pyemia*  etc.) 

Definition. — A  variety  of  conditions,  due  to  infection  of 
the  child  with  the  ordinary  pus-forming  bacteria,  are  met 
with.  The  staphylococcus  pyogenes  aureus  and  albus  and 
the  streptococcus  pyogenes  are  most  commonly  met  with. 

1  Thomson,  Edinburgh  Medical  Journal,  1892. 

2  Snow,  Archives  of  Pediatrics,  1903,  p.  659. 


DISEASES  OF  THE  NEWBORN.  55 

Etiology. — The  infection  may  be  localized,  and  the  ab- 
sorption of  toxins  may  cause  constitutional  symptoms,  or 
there  may  be  a  septicemia  or  pyemia.  Infection  frequently 
takes  place  through  the  umbilical  stump  ("omphalitis);  this 
may  extend  to  the  umbilical  vessels  or  even  to  the  peri- 
toneum. Peritonitis  is  one  of  the  most  frequent  forms  of 
septic  infection  met  with.  Bronchopneumonia,  associated 
with  pleurisy,  may  also  be  met  with  complicating  infection 
of  the  umbilical  vessels  or  other  inflammations.  Pericarditis 
is  rare.  Streptococcus  infection  of  the  throat  may  occur  with 
the  formation  of  a  false  membrane,  which  resembles  that 
seen  in  diphtheria. 

Gastro-enteritis  may  be  caused  by  pyogenic  organisms. 
Inflammation  of  the  cellular  tissue  with  abscess  formation  is 
common,  and  septic  arthritis  and  osteomyelitis  are  also  seen. 
Erysipelas  may  start  about  the  umbilicus  during  the  first  two 
weeks  of  life,  and  tliis  form  is  usually  fatal. 

Symptoms. — Certain  general  symptoms  are  common  to 
all  infections  in  the  newborn  ;  fever,  if  present,  is  of  the 
most  irregular  type.  Icterus  is  common,  and  hemorrhages 
frequent.  Loss  of  appetite,  vomiting,  and  diarrhea  are  fre- 
quently seen.  There  is  always  loss  of  weight.  The  pulse  is 
rapid  and  weak,  and  the  respiration  is  irregular.  Convul- 
sions, twitching,  and  rigidity  may  be  present,  and  coma  may 
come  on  later. 

Symptoms  of  special  infections,  as  peritonitis,  are,  if  pres- 
ent, like  those  seen  later  in  infancy.  There  may,  however, 
be  little  to  call  attention  to  the  seat  of  the  greatest  trouble. 

Prognosis. — This  is  always  bad. 

Prophylaxis,  along  general  antiseptic  lines,  should 
always  be  carried  out,  to  prevent  infection,  always  bearing  in 
mind  that  a  young  infant  is  easily  infected. 

Treatment. — This  is  symptomatic.  Collections  of  pus 
should  be  evacuated.  Ichthyol  (o  to  30  per  cent,  in  oint- 
ment) or  glycerin  is  useful  in  skin  infections. 


56  DISEASES  OF  INFANTS  AND   CHILDREN. 


OPHTHALMIA  NEONATORUM,1 

Ktiology. — This  is  caused  by  the  gone-coccus,  infection 
taking  place  from  the  vagina  of  the  mother  during  labor, 
occasionally  in  other  ways. 

Symptoms. — There  is  great  swelling  of  the  lids,  chemo- 
sis,  and  a  profuse  purulent  discharge.  If  the  progress  of  the 
disease  is  not  arrested,  ulceration  of  the  cornea,  or  panoph- 
thalmitis, with  total  loss  of  the  eye,  may  result.  The  dura- 
tion of  the  disease  depends  largely  on  the  treatment.  Gonor- 
rheal arthritis  may  occur  from  these  infections. 


„.:ssa«=s».== 


Fig.  14.— Ophthalmia  (conjunctivitis)  neonatorum  (de  Schweinitz). 

Prognosis. — The  outlook  is  good  if  the  case  is  taken 
early  and  energetically  treated.  If  handled  late  or  if  im- 
properly treated  the  prognosis  is  bad.  Nearly  one-third  of 
all  blindness  is  from  this  cause. 

Prophylaxis. — Every  child  born  in  an  institution,  and 
every  suspicious  case  in  private  practice,  should  receive  1  or 
2  drops  of  a  1  or  2  per  cent,  solution  of  nitrate  of  silver  in 
each  eye  (Crede's  method).  The  excess  of  silver  may  be 
neutralized  afterward  by  flushing  the  eye  with  normal  salt 
solution. 

1  Weeks,  Archives  of  Pediatrics,  May,  1905,  p.  346. 


DISEASES  OF  THE  NEWBORN. 


57 


Treatment. — Isolation  of  cases,  strict  antiseptic  precau- 
tions, and  cleanliness  are  necessary.  If  only  one  eye  is 
affected,  the  other  should  be  protected  by  pads  moistened  in 
some  antiseptic  solution.  Cold  compresses  of  surgical  gauze 
should,  almost  constantly,  be  kept  on  the  eyes.  These  may 
be  changed  every  few  minutes,  taking  them  directly  from  a 
block  of  ice   and  applying.      Every  twenty  minutes,  night 


Fig.  15.— Arrangement  for  application  of  ice  to  the  eyes  (De  Lee). 

and  day,  the  eye  should  be  irrigated  with  a  solution  of  boric 
acid  (10  gr.  to  1  oz.).  A  bulb-tip  eye-dropper  should  be 
usecl — alternately  at  the  inner  and  outer  canthus  of  the  eye — 
and  the  fluid  injected  with  sufficient  force  to  wash  out  the 
conjunctival  sac.  Once  or  twice  a  day  a  few  drops  of  a  3 
per  cent,  solution  of  protargol  (in  resistent  cases  a  10  per  cent, 
solution),  or  a  1  or  2  per  cent,  solution  of  nitrate  of  silver 


58  DISEASES  OF  INFANTS  AND  CHILDREN. 

should  be  dropped  into  each  eye.  Atropin  should  be  in- 
stilled if  the  cornea  is  affected.  Later  on  a  very  mild  oint- 
ment containing  yellow  oxid  of  mercury  may  be  used  to  keep 
the  abraded  conjunctiva  from  adhering. 

TETANUS.1 

Definition. — An  acute  infectious  disease  characterized 
by  tonic  muscular  spasms  (which  increase  in  severity  by  ex- 
acerbations) and  by  general  convulsions. 

Ktiology. — The  disease  is  caused  by  Nicolaier\s  tetanus 
bacillus,  which  produces  a  powerful  poison — tetanotoxin. 
The  bacilli  are  never  found  anywhere  in  the  body  except  at 
the  site  of  infection.  The  tetanus  bacillus  is  found  in  the 
soil.  In  some  places,  as  the  Hebrides,  Faroe  Islands,  and 
various  places  in  the  tropics,  the  disease  is  endemic,  and  a 
large  percentage  of  the  newborn  die  from  tetanus.  Infection 
in  infants  usually  takes  place  through  the  umbilical  wound. 

Pathology, — About  the  only  thing  found  is  hyperemia, 
sometimes  accompanied  with  small  hemorrhages  of  the  spinal 
cord.     Congestion  of  the  lungs  is  also  usually  noted. 

Symptoms. — The  disease  comes  on  usually  about  the 
fifth  or  sixth  day,  rarely  later  than  the  twelfth.  Trismus 
(stiffness  of  the  jaws)  is  the  first  thing  noticed,  and  this  pre- 
vents nursing.  The  body  next  becomes  slightly  stiffened,  and 
this  increases  by  paroxysms  until  the  whole  body  is  rigid. 
The  head  is  generally  retracted,  and  the  fixation  of  the  mus- 
cles of  the  face  gives  a  peculiar  expression.  Convulsions 
are  apt  to  be  excited  by  any  manipulation.  The  pulse  is 
rapid  and  weak,  the  temperature  in  the  mild  cases  is  low, 
100°  to  101°  F.,  but  may  be  104°  to  105°  F.,  or  even  higher 
in  the  severer  cases.  In  the  fatal  cases  death  usually  takes  place 
in  from  twenty-four  to  forty-eight  hours,  sometimes  later  ; 
those  which  recover  last  from  one  to  three  weeks,  the  spasm 
gradually  passing  away.  Death  takes  place  from  exhaustion 
or  from  spasm  of  the  glottis  or  of  the  muscles  of  respiration. 

Prognosis. — This  is  always  bad — 90  to  95  per  cent,  of 
the  cases  die. 

1  Hartigan,  American  Journal  of  the  Medical  Sciences,  1884. 


DISEASES  OF  THE  NEWBORN.  59 

Treatment. — Drugs  tending  to  lower  the  spinal  excita- 
bility should  be  used,  in  repeated  doses,  in  quantities  suffi- 
cient to  produce  some  effect.  Chloral  and  bromides,  either 
alone  or  in  combination,  are  most  used.  Calabar  bean  is 
also  recommended.  From  3  to  5  gr.  or  more  of  bromid  of 
soda  or  potash  may  be  given  every  two  or  three  hours,  re- 
ducing the  dose  as  improvement  takes  place.  Chloral  may 
be  used  in  1  or  2  gr.  doses,  and  may  be  increased.  It  may 
be  given  every  hour  or  two  until  some  effect  is  produced. 

Phenol  has  given  remarkable  results.  It  is  used  in  a  10 
per  cent,  solution,  the  adult  dose  being  10  drops,  children  in 
proportion.  This  should  be  diluted  with  25  to  30  minims 
of  water.  It  should  be  given  deep  into  the  muscles.  It 
may  be  repeated  at  intervals  of  three  hours,  and  less  fre- 
quently as  improvement  takes  place.  The  urine  should  be 
watched,  and  if  it  becomes  dark  it  should  be  stopped,  at 
least  temporarily. 

Tetanus  antitoxin  should  be  given  as  soon  as  possible. 
From  1500  to  3000  units  of  the  standard  adopted  by  the 
United  States  Public  Health  and  Marine  Hospital  Service 
may  be  given,  and  repeat  it  once  or  twice  if  necessary. 

Tetanus  in  Older  Children. — A  very  large  number  of  cases 
of  tetanus  occur  every  year,  usually  about  the  Fourth  of  July, 
as  a  result  of  injuries  received  from  the  explosion  of  fire- 
works, a  large  majority  of  cases  coming  from  the  use  of  blank 
cartridges.  Toy  pistols  made  for  the  explosion  of  blank 
cartridges  should  be  prohibited. 

To  prevent  tetanus,  the  wound  should  be  freely  incised 
and  every  particle  of  foreign  matter  carefully  removed.  It 
should  then  be  cauterized  with  a  25  per  cent,  solution  of  car- 
bolic acid  and  a  loose  wet  boric  acid  dressing  applied,  and  the 
wound  allowed  to  heal  by  granulation.  The  dressing  should 
be  changed  once  a  day  or  oftener  if  necessary;  1500  units 
of  tetanus  antitoxin  should  be  administered,  and  this  is  almost 
a  certain  prophylactic. 

The  child  should  be  kept  absolutely  quiet  and  not  touched 
unless  absolutely  necessary.  Food  and  medicine  may  be 
given  by  means  of  a  nasal  tube, 


60  DISEASES  OF  INFANTS  AND  CHILDREN. 

PEMPHIGUS, 

This  disease  is  characterized  by  a  blister-like  eruption, 
which  may  be  due  to  a  variety  of  causes.  The  lesion  is  a 
bulla,  varying  in  size  from  one-quarter  of  an  inch  to  several 
inches,filled  with  clear  serum, and  usually  upon  a  reddened  base. 

Btiology. — Epidemic  pemphigus  of  the  newborn  some- 


Fig.  16.— Pemphigus. 


times  occurs  in  institutions.  It  usually  begins  the  latter 
part  of  the  first  week,  but  may  be  seen  later.  It  is  probably 
due  to  several  sorts  of  pus-forming  bacteria.  Staphylococcus 
pyogenes  albus  and  aureus  have  been  found  in  the  bulla?. 

Symptoms. — There  are  twenty  or  thirty  bulla?  scattered 
over  the  body,  but  seldom  on  the  soles  or  palms.  They  may 
appear  on  the  mucous  membranes.  After  a  day  or  two  they 
burst  and  dry  up,  and  a  few  days  later  the  scab  falls,  leaving 


DISEASES  OF  THE  NEWBORN.  61 

a.  reddish-violet  base.  New  crops  may  appear.  The  disease 
lasts  a  week  or  two. 

Prognosis. — This  is  usually  good  in  strong  infants.  Sep- 
sis may  develop  and  prove  fatal. 

Diagnosis. — Impetigo  may  resemble  it  very  closely,  and 
the  two  may  be  only  different  forms  of  the  same  process. 

Treatment. — Keep  the  child  clean  by  bathing  in  mild 
antiseptic  solutions,  such  as  boric  acid  (10  gr.  to  1  oz.)  or 
1  :  10,000  bichlorid  of  mercury.  An  antiseptic  powder 
(mixture  of  boric  acid  and  starch)  or  an  ointment  may  be 
used.  The  best  ointments  are  either  a  1  per  cent,  ichthyol 
or  a  1  to  2  per  cent,  ammoniated  mercury  ointment. 


Fig.  17.— Pemphigus. 

Traumatic  pemphigus  may  result  from  bathing  the  child  in 
very  hot  water. 

Syphilitis  pemphigus  may  be  present  at  birth,  or  may 
develop  during  the  first  two  weeks  of  life,  rarely  later.  It 
is  frequently  seen  upon  the  soles  and  palms  *  other  manifesta- 
tions of  congenital  syphilis  are  present.     (See  Syphilis.) 


62  DISEASES  OF  INFANTS  AND   CHILDREN. 

FATTY  DEGENERATION  OF  THE  NEWBORN. 
(Buhl's  Disease,  186 J.) 

Definition. — This  is  a  rare  disease,  seen  usually  in 
infants  who  have  been  asphyxiated  at  birth  and  in  whom 
the  symptoms  have  persisted  to  a  greater  or  less  degree. 
The  attempts  at  resuscitation  may  not  always  be  successful. 
The  cause  of  the  disease  is  unknown. 

Pathology. — The  features  of  the  disease  are  fatty  de- 
generation of  the  organs  (especially  the  heart,  liver,  and 
kidneys)  and  hemorrhages  into  the  organs,  the  serous  cavi- 
ties, and  from  the  mucous  membranes.  There  may  be  hem- 
orrhage from  the  cord  when  it  separates. 

Symptoms. — There  is  prostration,  loss  of  weight,  and 
sometimes  icterus  and  edema ;  external  hemorrhages  may 
occur.  There  is  no  temperature.  The  disease  usually  proves 
fatal  within  two  weeks. 

Diagnosis. — This  is  made  by  microscopic  examination 
of  the  organs,  and  may  be  of  some  medicolegal  importance 
in  cases  of  asphyxia.  It  resembles  the  pyogenic  infection  of 
the  newborn.  Phosphorus  and  arsenical  poisoning  should 
also  be  excluded. 

Treatment. — This  is  symptomatic.  Nothing  known 
has  any  influence  over  the  course  of  the  disease. 


EPIDEMIC  HEMOGLOBINURIA.1 
("wmckePs  Disease,  1879;  Maladie  bronse'e.) 

Definition, — This  is  a  rare  disease  of  the  newborn, 
usually  occurring  epidemically  in  institutions.  It  is  charac- 
terized by  hemoglobinuria,  icterus,  and  cyanosis. 

Etiology. — It  is  probably  due  to  some  sort  of  infection 
as  yet  unknown. 

Pathology. — The  lesions  are  swollen  kidney,  large  hard 
spleen,  hemorrhages  into  the  various  organs,  and  sometimes 
fatty  degeneration  of  the  heart  and  liver.  The  umbilical 
vessels  are  almost  always  normal. 

Symptoms. — The  disease  attacks  previously  healthy  in- 
fants, and  comes  on  from  the  fourth  to  the  eighth  day  after 

1  Boston  Medical  and  Surgical  Journal,  March,  1875. 


DISEASES  OF  THE  NEWBORN.  63 

birth.  It  begins  suddenly,  with  restlessness,  followed  by 
great  prostration,  rapid  pulse,  and  respiration.  The  increas- 
ing cyanosis  and  icterus  together  give  the  child  the  appear- 
ance of  a  mulatto.  The  urine  is  dark  and  cloudy,  is  passed 
in  small  quantities,  with  pain  and  straining,  and  contains 
hemoglobin,  kidney  epithelium,  and  sometimes  granular  casts 
and  blood,  but  no  bile.  The  temperature  is  either  normal  or 
elevated.  The  child  usually  dies  in  thirty  or  forty  hours 
from  asthenia,  coma,  or  convulsions. 

Treatment. — This  is  symptomatic.  Nothing  known  in- 
fluences the  course  of  the  disease. 

HEMORRHAGES. 

Hemorrhages  are  common  in  early  life.  They  may  be 
(1)  traumatic ;  (2)  spontaneous,  the  so-called  hemorrhagic 
disease  of  the  newborn. 

1.  Traumatic  hemorrhages  are  due  to  injury  during 
labor — if  the  skin  is  unbroken  a  hematoma  results. 

Cephalhematoma  is  due  to  prolonged  labor  or  forceps.     It 


Fig.  18.— Cephalhematoma  (Hirst). 

is  a  collection  of  blood  under  the  scalp,  usually  over  one 
parietal  bone.  It  may  be  noted  any  time — from  birth  to  the 
fourth  day.  It  increases  in  size  for  about  a  week  and  then 
slowly  disappears.     Xo  treatment  is  required. 

Differential  Diagnosis. — Cephalhematoma. — Soft ;  fluctuates ; 
not  reducible ;  no  pressure  symptoms  ;  no  pulsation  (may 
rarely  pulsate)  ;  no  heat ;  marginal  ridge  ;  skull  felt  at  bottom  ; 
disappears  in  from  one  to  three  months. 

Caput  Succedaneum. — Edematous  ;  does  not  fluctuate  ;  dis- 
appears in  two  or  three  days. 


64 


DISEASES  OF  INFANTS  AND   CHILDREN. 


Abscess. — Soft ;  fluctuates ;  not  reducible ;  no  pressure 
symptoms  ;  local  heat ;  redness  ;  often  fever. 

Encephalocele. — Along  line  of  sutures  partly  reducible; 
pressure  causes  symptoms.  Increases  on  crying  (see  En- 
cephalocele). 

Depressed  Fracture. — Depression  of  skull  felt ;  sometimes 
paralysis,  coma,  etc. 

Hydrocephalus. — Symmetrical  enlargement  of  the  head. 

Hematoma  of  the  Sternomastoid. — A  condition  noted  during 
the  second  or  third  week,  most  frequently  after  breech  pre- 


Fig.  19.— Longitudinal  section  through  a  cephalhematoma:    a,  Dura  mater;   b, 
cranium  ;  c,  pericranium  ;  c' ,  c',  beginning  hyperostosis  ;  e,  scalp  (Davis). 

sentation.  It  is  a  hard  tumor,  about  the  size  of  a  pigeon's 
egg,  situated  in  the  muscle.  It  is  immovable  and  sometimes 
slightly  tender.  It  disappears  spontaneously,  leaving  no  de- 
formity.    Treatment  is  contra-indicated. 

Visceral  Hemorrhages. — These  may  be  in  the  brain,  lungs, 
or  abdominal  organs.  The  intracranial  may  be  diagnosed 
by  the  nervous  symptoms  (see  Birth  Palsies) ;  that  of  the 
lungs  may  occasionally  cause  hemoptysis ;  abdominal  hemor- 
rhage causes  obscure  symptoms,  often  fatal  collapse,  and  diag- 
nosis is  rarely  made  during  life. 

2.  Spontaneous  Hemorrhage.1 — Small  hemorrhages 
may  occur  in  the  course  of  syphilis,  pyemia,  and  other  infec- 
tions. Small  or  large  hemorrhages  may  occur  without  any 
apparent  cause.  Do  not  confuse  with  hemophilia  (see  Hemo- 
philia). Various  bacteria  have  been  demonstrated  in  the 
blood  of  these  patients.  The  hemorrhages  may  vary  in 
size  from  a  pin-point  ecchymosis  to  a  large  loss  of  blood. 
1  Townsend,  Archives  of  Pediatrics,  August,  1894,  p.  559. 


DISEASES  OF  THE  NEWBORN.  65 

They  may  be  single  or  multiple  and  may  occur  in  any  organ, 
into  any  serous  cavity,  from  any  mucous  membrane,  or  under 
the  skin.  Townsend  gives  oO  cases  as  follows  :  Intestine,  20  ; 
stomach,  14;  mouth,  14;  nose,  12;  umbilicus,  18  (umbili- 
cus alone,  3) ;  subcutaneous,  2  ;  abrasions  of  the  skin,  1  ; 
meninges,  4  ;  cephalhematoma,  3  ;  abdomen,  2  ;  pleura,  1  ; 
thymus,  1.  The  hemorrhages  occur  usually  on  the  second 
or  third  day,  rarely  later  than  the  seventh  day.  There  may, 
or  may  not,  be  temperature.  There  is  rapid  loss  of  weight. 
Death  takes  place  in  most  cases  in  three  or  four  days,  or  else 
the  hemorrhages  stop  spontaneously  (generally  within  the  first 
day  or  two  of  the  disease),  and  recovery  takes  place.  Town- 
send  collected  709  cases  ;  79  per  cent,  of  these  died. 

Treatment. — Keep  up  nutrition.  Local  treatment,  where 
the  hemorrhage  can  be  reached.  One  drop  of  the  1  :  1000 
solution  of  adrenalin  diluted  with  normal  salt  solution  may 
be  given  hourly  for  a  few  doses  or  until  some  effect  is  noted. 
The  dried  gland  may  be  given  in  J-grain  doses  internally. 
For  local  bleeding,  adrenalin  solution  1  :1000  diluted  1  :  10 
with  normal, salt  solution  may  be  used.  Gelatin  (2  per  cent, 
solutions)  in  normal  salt  solution  sterilized  several  times  has 
been  recommended.  It  should  be  boiled  for  several  hours. 
Injections  of  from  2  drams  to  \  ounce  may  be  used,  and 
repeated  if  no  effect  is  produced.  Normal  horse  serum  has 
also  been  suggested  as  an  injection.  Human  blood  serum 
has  also  been  used,  10  cc.  subcutaneously  three  times  a  day, 
or  even  every  two  hours  in  severe  cases. 

Intracranial  hemorrhage  is  sometimes  amenable  to  surgical 
treatment.1 

INTESTINAL  OBSTRUCTION.2 

In  the  newborn  this  is  most  frequently  due  to  an  imper- 
forate anus,  usually  only  the  external  orifice  being  absent. 

1  Gushing,  American  Journal  of  Medical  Sciences,  October,  1905,  p.  563. 
J.  E.  Welch,  "  Normal  Human  Blood  Serum,"  etc.,  The  American  Journal 
of  the  Medical  Sciences,  June  1910,  p.  800. 

'  Journal  of  the  American  Medical  Association,  January  21,  1905.  Arthur 
Edmunds,  "  Intestinal  Obstruction  in  Children,"  Practitioner,  August,  1906, 
p.  173.  G.  P.  la  Eouge,  "Intestinal  Obstruction,  Diagnosis  of  Affections 
Characterized  by,"  Journal  of  the  American  Medical  Association,  April  7, 
1906.  J.  E.  Erdmann,  "  Intestinal  Obstruction  in  Children,"  Journal  of 
the  American  Medical  Association,  January  21,  1905,  p.  171. 

5 


6Q  DISEASES  OF  INFANTS  AND  CHILDREN. 

The  rectum  may  be  absent  in  part  or  entirely  or  be  closed 
by  a  septum.  The  obstruction  may  be  due  to  malformations 
higher  up  in  the  gut. 

The  symptoms  vary  with  the  grade  of  obstruction.  Ab- 
sence of  stools — or,  if  high  up,  absence  of  stools  after  the 
first  few — vomiting,  and  distension  of  the  belly  are  the  most 
common  symptoms.  These  may,  in  some  instances,  come  on 
after  a  week  or  two.  The  lower  the  obstruction  the  longer 
the  child  lives.  The  higher  up  the  obstruction  the  earlier 
the  symptoms  come  on. 

Imperforate  anus  and  rectal  septum  may  be  treated  surgi- 
cally with  success.  The  other  forms  are  practically  always 
fatal. 

DIAPHRAGMATIC  HERNIA,1 

This  is  a  congenital  deformity.  More  or  less  gut  is  found 
protruding  upwards  through  the  diaphragm,  usually  on  the 
left  side.  If  the  hernia  is  small  the  child  may  live.  The 
symptoms  are  usually  dyspnea  or  asthmatic  attacks.  There 
may  be  signs  of  a  pneumothorax  and,  if  on  the  left  side,  the 
heart  is  pushed  to  the  right.  Diagnosis  is  difficult  or  impos- 
sible, and  there  is  nothing  to  do  for  it. 

MASTITIS. 

In  the  breast  of  the  newborn  it  is  very  common,  to  find 
milk  secreted.  This  is  most  marked  about  the  second  week, 
but  it  may  be  noted  for  several  months.  Left  to  itself,  it 
rarely  causes  any  trouble,  but  if  squeezed  out  or  handled 
roughly  the  breast  is  apt  to  become  inflamed  and  an  abscess 
caused,  which  may  prove  fatal.  The  breast  of  infants  should 
be  kept  clean  and  let  alone. 

Treatment. — For  abundant  milk  paint  the  gland  with 
tincture  of  belladonna  and  apply  a  large  pad  of  cotton,  and 
over  this  a  roller  bandage,  making  moderate  pressure.     If 

!Abt,  Archives  of  Pediatrics,  April,  1900,  p.  261.  Stiles,  "Operative 
Treatment  of  Hernia  in  Infants,"  British  Medical  Journal,  October,  1901,  p. 
813.  W.  B.  Coley,  "  Hernia,  Management  of,  in  Infancy  and  Childhood,-' 
Journal  of  the  American  Medical  Association,  January  11, 1905,  p.  112.  R.  H. 
Russell,  "Hernia  in  Children  and  Their  Relation'to  Adult  Conditions,  Pa- 
thology and  Treatment  of,"  Lancet,  January  7, 1905,  p.  7.  Edmund  Owen, 
"  Hernia,  Reducible,  in  Boyhood,"  Practitioner,  March,  1906,  p.  289. 


DISEASES  OF  THE  NEWBORN. 


67 


the  gland  becomes  inflamed  apply  hot  boric-acid  solution  on 
compresses.     If  an  abscess  forms  it  should  be  opened. 

UMBILICAL  HERNIA. 

The  ordinary  form  consists  of  a  small  protrusion  of  gut 
through  the  umbilical  opening.  It  is  most  frequently  seen 
in  poorly  nourished,  rachitic  girls.  A  carefully  applied 
abdominal  binder  during  the  first  few  months  does  much  to 
prevent  its  occurrence,  and  in  the  smaller  ones  a  pad  of  gauze, 
held  in  place  by  the  binder,  is  all  that  is  necessary  to  effect 
a  cure.  Later  on  a  piece  of  cork  or  a  button,  covered  with 
a  gauze  and  held  in  place  with  two  strips  of  zinc  oxid  adhe- 
sive plaster,  applied  at  right  angles  and  crossing  at  the  um- 


Fig.  20.— Adhesive  plaster  applied  for  the  cure  of  umbilical  hernia  (De  Lee). 

bilicus,  will  be  found  efficient.     The  tendency  is  for  these 
hernias  to  disappear  even  without  treatment. 

LESIONS  OF   THE   UMBILICUS. 

Granuloma. — This  is  merely  an  excess  of  granulation 
tissue.  It  forms  a  small  tumor  mass,  has  a  small  amount  of 
discharge  and  bleeds  readily.  Powdered  burnt  alum  may  be 
used  as  a  dusting  powder  or  sulphate  of  copper  or  nitrate  of 
silver  may  be  applied.     If  large,  it  may  be  cut  off. 


68  DISEASES  OF  INFANTS  AND   CHILDREN. 

Adenoma ;  Mucous  Polypus ;  Diverticulum 
Tumor. — Names  applied  to  a  tumor  mass  at  the  umbilicus 
caused  by  a  prolapse  of  the  mucous  membrane  of  Meckel's 
diverticulum.  Various  sizes  and  degrees  are  met  with.  The 
tumor  is  of  a  pink  color,  smooth,  irreducible,  and  has  a  slight 
mucous  discharge.  There  may  be  a  fecal  fistula.  The  treat- 
ment is  surgical, 

SCLEREMA. 

A  curious,  hard,  board-like  condition  of  the  skin  and  sub- 
cutaneous tissues  occasionally  seen  in  the  newborn  and  also 
in  older  infants.  It  occurs  in  weak  infants.  It  may  be  in 
small  areas  or  may  extend  to  nearly  the  entire  surface  of  the 
body.  The  temperature  of  the  body  is  lowered  and  the  skin 
feels  like  a  cadaver.  There  is  no  pitting  on  pressure.  The 
body  may  be  rendered  quite  stiff  if  the  sclerema  is  extensive. 
The  circulation  is  very  feeble.  Most  of  the  cases  die,  but  not 
all. 

Treatment. — The  baby  should  be  put  in  an  incubator 
and  kept  warm.  The  heart  should  be  stimulated  and  the 
feeding  carefully  regulated. 

EDEMA. 

Edema  may  be  seen  in  young  infants  not  associated  with 
disease  of  the  heart,  liver,  kidneys,  or  blood.  It  is  usually 
seen  in  very  weak  infants  ;  it  may  be  general  or  local,  and 
is  most  frequent  in  the  dependent  parts.  As  it  occurs  in  the 
very  weak  the  children  often  die,  but  some  of  them  recover. 

The  edema  lasts  a  week  or  so  and  disappears.  It  may 
recur. 

Treatment. — Keep  the  child  warm  and  stimulate  the 
heart  and  circulation.  Give  digitalis,  strychnia,  and  alcohol. 
In  the  very  severe  cases  citrate  of^potassium  may  be  given. 

INANITION  FEVER. 

Inanition  must  not  be  forgotten  as  a  cause  of  fever  in  the 
newborn.     (See  Inanition). 


INFANT  FEEDING.  69 

INFANT   FEEDING.1 

There  are  four  methods  of  feeding  infant-  :  1.  Breast  or 
maternal  feeding.  2.  Wet-nursing.  3.  Mixed  feeding — i.  e.9 
breast-feeding  supplemented  by  bottle-feeding.  4.  Bottle  or 
artificial  feeding. 

BREAST-FEEDING. 

The  milk  from  a  healthy  mother  is  by  far  the  best  nour- 
ishment for  an  infant  during  the  first  year,  and  cannot  be 
fully  replaced  by  any  other  form  of  feeding.  Infants  fed  on 
breast  milk  are  stronger  and  better  able  to  resist  disease. 
While  it  remains  true  that  babies  may  be  reared  on  artificial 
foods  and  remain  healthy  and  grow  strong,  the  percentage  of 
robust  bottle-fed  babies  is  much  smaller  than  that  of  healthy 
breast-fed  infants.  This  is  particularly  true  of  the  lower 
classes,  who  often  lack  both  the  time  and  intelligence  re- 
quired to  rear  a  healthy  infant  by  bottle-feeding. 

Contra-indications  to  Maternal  Nursing. — The 
following  rules,  adapted  from  Holt,  will  be  found  a  reliable 
guide  in  determining  whether  or  not  a  mother  is  fitted  to 
nurse  her  child  : 

1.  If  the  mother  has  tuberculosis  in  any  form,  latent  or 
active,  she  should  not  nurse  her  child.  A  tuberculous  mother 
not  only  exposes  her  child  to  infection,  but  hastens  the  prog- 
ress of  the  disease  in  herself.  If  the  mother  has  pulmonary 
tuberculosis,  nursing  is  almost  certain  to  prove  fatal  to  her. 

2.  When  the  mother  has  had  any  serious  complication, 
such  as  nephritis,  convulsions,  severe  hemorrhages,  or  septic 
infection,  during  pregnancy  or  parturition,  she  should  not 
nurse  her  child. 

3.  If  the  mother  is  choreic  or  epileptic,  nursing  is  contra- 
indicated. 

4.  If  the  mother  is  very  feeble  or  has  any  serious  chronic 
disease  the  child  will  derive  little,  if  any,  benefit  from  breast- 
feeding, and  the  mother  will  be  greatly  injured. 

1  A  very  complete  discussion  of  this  subject  will  be  found  in  Diet  in 
Health  and  Disease,  by  Friedenwald  and  Ruhrah. 


70  DISEASES  OE  INEANTS  AND  CHILDREN. 

5.  Nursing  should  not  be  attempted  where  experience  has 
shown  on  two  previous  occasions,  under  favorable  conditions, 
that  the  mother  is  unable  to  nourish  her  child. 

6.  Where  no  milk  is  secreted  nursing  is  impossible. 
Good  artificial  feeding  is   to  be  preferred  to  poor  breast 

feeding.  If  artificial  feeding  is  to  be  resorted  to  it  is  well  to 
begin  early,  while  the  infant's  digestive  organs  are  in  com- 
paratively good  condition.  The  question  must  always  be 
carefully  considered. 

During  pregnancy  the  breasts  should  be  examined,  and  if 
the  nipples  are  short,  gentle  traction  should  be  made  on  them 
daily.  If  there  is  retraction  the  breast-pump  may  be  needed 
to  evert  them.     During  the  entire  nursing  period  the  breasts 


Fig.  21.— Breast-pump. 

should   be   kept  clean  ;   they   should   be   washed   after  each 
nursing,  preferably  with  a  boric-acid  solution. 

During  the  first  forty-eight  hours  the  child  receives  practi- 
cally no  nourishment  from  the  breast ;  the  only  fluid  secreted 
during  this  time  is  colostrum.  This  has  a  laxative  effect 
upon  the  infant's  bowels,  emptying  them  of  the  dark,  brown- 
ish material  known  as  meconium,  which  has  accumulated  in 
the  intestinal  canal  during  uterine  life.  The  child  should, 
however,  be  put  to  the  breast  at  regular  intervals,  so  as  to 
establish  a  free  flow  of  milk  ;  this  generally  begins  on  the 
third  day,  but  is  sometimes  delayed. 

During  the  first  two  days  of  its  existence  the  child  gets 
about  six   ounces  of  colostrum  a  day,  which  is  all  that  is 
needed.     It  may,  however,  be  given  a  teaspoonful  or  two  of 
warm,  boiled  water  or  of  a  5  per  cent,  solution  of  sugar  of 


INFANT  FEEDING. 


71 


milk.  In  unusually  robust  and  fretful  children,  or  when 
there  is  fever,  a  small  amount  of  nourishment  may  be  re- 
quired ;  this  should  be  given  according  to  the  rules  for  arti- 
ficial feeding.  If  the  milk  is  delayed  beyond  forty-eight 
hours,  it  becomes  necessary  to  feed  the  child  by  the  bottle 
until  the  flow  is  established.  The  child  should  be  put  to 
the  breast  regularly,  or  the  breast-pump  may  be  used  to 
stimulate  the  secretion  of  the  milk.  Fennel,  catnip  tea,  and 
the  like  should  be  excluded  from  the  child's  dietary. 

Many  mothers  do  not  nurse 
their  infants  because  they  have 
not  been  properly  instructed 
as  to  the  importance  of  doingit. 

The  mental  attitude  of  the 
mother  has  a  marked  effect  on 
the  milk  secretion,  and  if  she 
has  been  properly  instructed 
and  encouraged  beforehand, 
there  is  usually  no  difficulty. 
If,  on  the  other  hand,  she  has 
grave  doubts  as  to  her  capa- 
bility, the  milk  secretion  may 
be  inhibited.  The  mental 
condition  of  the  mother  is 
often  affected  as  the  result 
of  weighing  the  child.  It  is  very  desirable  that  the  child  be 
weighed  regularly  and  the  weight  recorded  ;  but  if  the  mother 
is  at  all  nervous,  or  if  the  child  is  not  doing  well,  the  weigh- 
ing should  not  be  done  by  the  mother  or  in  her  presence. 

Breast-nursing  often  proves  a  failure  because  the  mother 
does  not  understand  how  to  give  the  breast  to  the  child.  The 
child  should  lie  on  the  right  or  left  arm,  according  to  whether 
the  child  is  to  nurse  at  the  right  or  at  the  left  breast.  If  the 
mother  is  in  a  sitting  posture,  her  body  should  he  inclined 
slightly  forward.  With  her  free  hand  she  should  grasp  the 
breast  near  the  nipple  between  the  first  two  fingers.  If, 
owing  to  the  free  flow  of  milk,  the  child  takes  the  milk  too 
rapidly,  this  may  be  checked  by  slight  pressure  of  the  fingers. 
The  child  should  nurse  until  satisfied.     The  contents  of  one 


Fig.  22.— Colostrum  and  ordinary  milk- 
globules,  first  day  labor ;  primipara  aged 
nineteen  (Durlandj. 


72  DISEASES  OF  INFANTS  AND   CHILDREN. 

breast  are  generally  sufficient  for  one  nursing,  and  the  breasts 
should  be  used  alternately.  When  satisfied,  the  infant  will 
usually  fall  asleep  at  the  breast.  Under  ordinary  conditions 
the  nursing  should  last  from  ten  to  twenty  minutes.  If  the 
milk  is  taken  too  rapidly,  vomiting  may  ensue  immediately 
after  or  during  feeding.  If  too  much  is  taken,  it  is  regurgi- 
tated almost  immediately.  If  the  infant  consumes  more  than 
half  an  hour  in  nursing,  the  breast  and  the  milk  should  be 
examined.  As  the  infant  grows  older  it  requires  and  takes 
more  food,  and  consequently  will  require  a  longer  time  to 
nurse  than  it  did  during  the  early  days  of  life. 

The  inculcation  of  good  nursing-habits  cannot  be  too 
strongly  insisted  upon.  Many  attacks  of  indigestion,  colic, 
and  diarrhea  may  be  traced  to  improper  nursing.  When 
good  habits  are  once  established,  there  is  generally  very  little 
trouble,  the  success  of  the  training  depending  largely  on  the 
manner  on  which  it  is  done.  Regular  hours  for  feeding 
should  be  fixed  and  adhered  to ;  and  if  the  child  is  asleep  at 
the  feeding-hour,  it  may  be  aroused,  for  it  will  almost  invari- 
ably go  to  sleep  after  nursing.  After  the  last  feeding,  which 
should  usually  take  place  at  9  or  10  o'clock,  the  child  should 
be  quieted  and  allowed  to  sleep  as  long  as  it  chooses. 

During  the  first  month  or  two  the  infant  will,  as  a  rule, 
awaken  between  1  or  2  o'clock  and  again  at  4  or  5  o'clock. 
After  two  or  three  months  it  will  require  but  one  night  feed- 
ing, and  after  five  months  of  age  the  average  infant  will  sleep 
all  night  without  nursing. 

When  the  change  is  being  made  and  the  child  awakens  for 
its  accustomed  nursing  it  should  be  given  a  little  warm  water 
from  a  bottle  and  quieted,  but  not  taken  up.  Regular  nurs- 
ing habits  induce  regular  bowel  movements  and  sleep,  and 
the  three  combined  insure  health  and  comfort  not  only  for 
the  infant,  but  for  the  mother  as  well.  A  healthy  child,  if 
trained  to  do  so,  will  sleep  without  rocking  or  coddling. 
Three  things  are,  however,  essential  to  secure  success  in  this 
training  :  a  satisfied  appetite,  dry  napkins,  and  a  quiet  dark- 
ened room.  If  it  has  colic,  the  warm  milk  may  soothe  the 
child  for  a  time,  but  later  aggravates  the  trouble,  which  in 
many  cases  is  due  to  overfeeding  or  too  frequent  feeding. 


INFANT  FEEDING. 


73 


The  following  table,  from  Holt,  may  be  used  as  a  guide  in 


breast-feeding 


Age. 


First  day 

Second  day , 

Third  to  twenty-eighth  day 
Fourth  to  thirteenth  week 
Third  to  fifth  month     .    . 
Fifth  to  twelfth  month     . 


Number  in 

Intervals 

Night  nursing 

twenty-four 

during 

between  9  I  .  M. 

hour-. 

day. 

and  7  A.  M. 

4 

6  hours. 

1 

6 

4      " 

1 

10 

2      " 

2 

8 

2^    " 

1 

7 

3      " 

1 

6 

3      " 

0 

In  case  of  sickness  and  when  the  infant  is  feeble  and 
below  the  average,  especial  rules  are  required,  and  directions 
should  be  modified  to  suit  each  individual  case.  A  good 
general  rule  is  to  feed  the  child  according  to  the  age  to  which 
the  weight  corresponds.  The  child'.-  weight  is  the  best  index 
of  its  nutrition.  During  the  first  six  months  it  may  be 
weighed  once  a  week ;  after  that  time  twice  a  month  is  suffi- 
cient. The  average  minimum  gain  for  an  infant  is  four 
ounces  a  week.  If  the  weight  falls  below  this  for  several 
weeks  consecutively,  it  is  evident  that  something  is  wrong. 
During  illness,  of  course,  there  may  be  no  gain  or  loss  ac- 
cording to  the  severity  of  the  condition. 

When  the  breast  milk  is  insufficient  for,  or  unsuited  to  the 
needs  of  the  infant,  it  becomes  fretful,  colic  occurs,  and  the 
baby  appears  to  be  "cross/'  Disturbances  of  the  alimentary 
tract,  diarrhea  with  greenish  stools  containing  a  large  amount 
of  mucus  and  undigested  curds,  takes  place  at  times.  At  times 
the  stools  are  brownish,  and  contain  mucus  and  numerous 
curds  the  size  of  a  grain  of  wheat  or  larger.  In  other  cases 
there  may  be  chronic  constipation  with  small,  hard,  dry  stool-. 

If  the  infant  is  getting  too  little  milk,  it  is  fretful  and  gains 
slowly  or  not  at  all,  but  there  is  rarely  any  disturbance  of 
the  stomach  or  bowels.  In  these  cases  the  nursing  is  con- 
tinued for  over  thirty  minutes  without  satisfying  the  child, 
or  it  may  nurse  a  minute  or  two  and  then  refuse  because 
the  supply  is  so  scanty.  AVheu  the  breast  milk  is  nearly 
normal  in  quantity  and  in  quality,  certain  measures,  which  will 
be  discussed,  may  be  taken  to  augment  the  supply  and  enrich 
the  quality,  or  it  may  be  supplemented  by  artificial  feeding. 


74 


DISEASES  OF  INFANTS  AND  CHILDREN. 


When  the  milk  is  very  poor  in  quality,  as,  for  example,  when 
the  specific  gravity  is  from  1.015  to  1.025  and  when  only  2 
or  3  per  cent,  of  cream  is  present,  the  child  should  be  weaned 
at  once,  for  the  condition  is  not  amenable  to  treatment. 

Mother's  milk  may  easily  be  tested  by  means  of  Holt's 
milk  set,  which  consists  of  a  lactometer  and  a  cream  gauge.1 
With  this  the  specific  gravity  and  the  amount  of  cream  may 
easily  be  estimated.  Estimated  with  this  instrument  the 
cream  is  to  the  fat  as  5  is  to  3.  The  following  table  will 
help  in  estimating  the  quality  of  human  milk  : 


Specific 

gravity, 

70°  F. 

Cream,  twenty-four 
hours. 

Normal  average   .  .  . 
Healthy  variations  .   . 

1.031 
1.028-1.029 

7  per  cent. 
9-12  per  cent. 

Healthy  variations  . 

1.032-1.033 

5-6  per  cent. 

Unhealthy  variations 

Below  1.028 

High  (above  10  per  cent.). 

Variations 

Below  1.028 
Below  1.028 

Normal  (5-10  per  cent.). 
Low  (below  5  per  cent.). 

Above  1.033 

High. 

Above  1.033 
Above  1.033 

Normal. 
Low. 

Proteins. 


1.5  per  cent. 
Normal  (rich 

milk). 
Normal  (fair 

milk). 
Normal  or  slightly 

below. 
Low. 
Very  low  (very 

poor  milk) 
Very  high  'very 

rich  milk). 
High. 
Normal  or  nearly 

so. 


When  the  mother's  milk  is  found  not  to  agree  with  the 
infant,  it  may  often  be  modified  by  the  following  means  : 

1 .  If  the  milk  is  too  rich,  the  diet  should  be  limited,  espe- 
cially as  to  the  amount  of  meat  taken.  All  alcoholic  and 
malted  drinks  should  be  prohibited.  With  plenty  of  fresh 
air  and  exercise,  such  as  walking,  the  desired  effect  will  gen- 
erally be  brought  about.  The  exercise  should  be  carried  to 
the  point  of  fatigue. 

2.  When  the  milk  is  good,  but  deficient  in  quantity,  the 
supply  may  be  augmented  by  massage  of  the  breasts  three 
times  a  day  for  from  five  to  ten  minutes.  A  good  malt  ex- 
tract may  be  given  with  the  meals,  and  fresh  air  and  exercise 
prescribed.    Sufficient  fluid  should  be  given,  preferably  milk. 

3.  When  the  milk  is  deficient  in  quantity  and  poor  in 
quality,  improvement  may  be  brought  about  by  various 
means ;  massage,  malt,  and  iron  are  to  be  prescribed  if  there 

1  This  may  be  obtained  from  Eimer  &  Amend,  New  York. 


INFANT  FEEDING.  ?5 

is  anemia.  An  alcoholic  malt  extract  combined  with  pep- 
tonate  of  iron,  or  of  iron  and  manganese,  is  a  good  combina- 
tion, and  may  be  had  in  very  palatable  form.  The  diet  should 
be  ample  and  contain  sufficient  nitrogenous  food.  Milk 
should  be  taken  with  the  meals,  during  the  intervals  between 
meals,  and  at  bedtime. 

4.  When  the  quantity  is  sufficient,  but  the  quality  is  poor, 
little  can  be  done,  and  the  child  must  generally  be  weaned. 
The  foregoing  measures  may  be  tried,  but  not  for  too  long  a 
period,  as  the  child  may  suffer  in  consequence. 

After  the  second  month  the  child  may  be  given  a  bottle 
once  a  day.  The  child  learns  to  take  its  milk  from  the  bottle, 
which  facilitates  weaning  when  the  time  comes ;  it  also  allows 
the  mother  greater  liberty. 

Wet-nursing". — Some  infants  will  thrive  on  nothing  but 
breast  milk.  If  the  mother  cannot  nurse  her  child  a  wet- 
nurse  should  be  chosen  according  to  the  following  rules  : 

The  woman  should  be  healthy  and  of  good  habits.  The 
absence  of  syphilis,  tuberculosis,  alcoholism,  and  other  dis- 
eases should  be  determined  by  careful  examination.  The 
nipples  should  be  carefully  examined  for  fissures  and  ulcera- 
tion. The  breasts  should  be  examined  before  and  after  nurs- 
ing, and  the  milk  tested  as  previously  described.  The  size 
of  the  breast  alone  is  not  a  good  guide  as  to  the  amount  or 
quality  of  the  milk  it  secretes.  The  quantity  may  be  judged 
by  the  size  of  the  breast  before  and  after  nursing  or  by 
weighing  the  babv  before  and  after  nursing.  This  latter 
method,  although  a  good  oue,  is  not  usually  resorted  to. 
The  wet-nurse  should  always  be  one  who  has  nursed  her 
own  child  successfully  for  at  least  a  month.  If  possible  she 
should  be  a  primipara  between  twenty  and  thirty-five  years 
of  age.  Younger  or  older  women  should  not,  as  a  rule,  be 
employed.  If  the  infantas  condition  permits,  the  purse  should 
be  given  at  least  a  week's  trial,  for  often  the  change  in  her 
mode  of  living  may  cause  a  scanty  flow  of  milk  or  render  it 
otherwise  unsatisfatory.  When  she  has  become  accustomed 
to  her  surroundings,  the  milk  may  become  perfectly  normal. 
Owing  to  idleness  and  a  too  abundant  diet  the  milk  may 
become  too  rich.  In  these  cases  the  rules  previously  laid 
down  may  correct  the  condition. 


76  DISEASES  OF  INFANTS  AND   CHILDREN. 

Wet-nursing  is  now  largely  replaced  by  correct  artificial 
feeding. 

MIXED  FEEDING. 

The  child  is  fed  partly  on  the  breast  and  partly  on  the 
bottle.  This  method  is  indicated  when  the  mother's  milk  is 
poor  or  scanty,  owing  to  some  intervening  illness,  or  when, 
owing  to  deficient  quantity,  the  mother  cannot  entirely  nurse 
the  child ;  it  is  also  useful  in  weaning.  Weaning  is  accom- 
plished with  less  discomfort  to  mother  and  child  if  done 
gradually.  If  the  mother  is  nursing  the  child  but  once  or 
twice  a  day,  her  milk  may  become  very  poor,  and  conse- 
quently should  be  examined  from  time  to  time.  In  these 
cases  the  child  is  usually  satisfied  after  a  bottle,  but  not  after 
the  breast-feeding. 

ARTIFICAL  OR  BOTTLE-FEEDING. 

When  it  becomes  necessary  to  feed  the  child  artificially 
the  physician  must  understand  the  nature  of  the  milk  mix- 
ture that  he  prescribes,  so  that  he  may  vary  it  to  suit  the 
child's  digestion  and  modify  it  to  meet  the  requirements  of 
the  growing  infant. 

In  the  United  States  the  only  milk  available  for  infant 
feeding  is  cows'  milk.  To  insure  success  by  artificial  feeding 
an  accurate  knowledge  of  the  composition  of  the  milk  and  in 
how  much  it  differs  from  mother's  milk  is  essential.  A 
knowledge  of  the  methods  for  overcoming  these  differences  is 
also  necessary.  It  should  constantly  be  borne  in  mind  that, 
while  general  deductions  may  be  made  and  average  figures 
given,  the  element  of  personal  equation  enters  largely  into 
the  problem,  and  each  infant  must  be  considered  a  law  unto 
itself.  Children  living  in  the  country  and  in  the  smaller 
towns,  where  there  is  no  overcrowding  and  where  an  abun- 
dance of  fresh  air  can  be  had,  seem  to  thrive  on  cows'  milk 
that  has  been  modified  but  little,  perhaps  merely  by  the  addi- 
tion of  water  in  various  proportions.  In  the  larger  towns, 
where  overcrowding  is  frequent  and  fresh  air  and  sunlight 
are  not  easily  secured,  the  question  is  a  more  difficult  one. 
Children  with  these  environments  require  a  more  exact  milk 


INFANT  FEEDISG.  77 

mixture  and  additional  care.  City  milk  is  often  stale  and 
preserved  by  the  addition  of  chemicals. 

The  first  requisite  in  artificial  feeding  is  a  pure,  fresh  milk. 
This  can  be  obtained  only  by  having  the  dairy  farms,  rattle, 
milk  production,  and  distribution  under  competent  supervision, 
and  by  cleanliness  and  care  in  the  handling  and  transportation 
of  the  milk.  Clean  cows,  clean  stables,  clean  milkers,  sterile 
milk  pails  and  utensils  are  necessary,  and  the  milk  should  be 
cooled  rapidly  after  milking  and  kept  cold  until  used.  Pas- 
teurization and  sterilization  should  be  necessary  only  under 
unusual  conditions.  They  are  often  necessary  now,  because 
the  milk  is  impure  to  start  with  and  improperly  cared  for. 
Xo  coloring  matter  or  preservatives  should  be  allowed.  In 
the  home  the  milk  should  be  kept  in  closed  jars  or  bottles 
until  used,  and  it  should  be  kept  cold.  Pure  milk  is  best 
secured  by  having  the  supervision  of  the  dairies  and  market- 
ing under  the  same  management.  Bacteriological  and  chemical 
analyses  are  necessary  from  time  to  time  to  control  the  work. 

In  order  to  adapt  cows'  milk  to  the  infant's  digestion 
several  changes  must  be  made  in  it.  These  become  apparent 
by  studying  the  nature  and  composition  of  the  milk. 

Composition  of  Cows'  Milk. — The  proteins  differ  not 
only  in  amount,  but  also  in  character.  In  human  milk  the 
proteins  consist  of  lactalbumin  and  casein,  in  the  proportion 
of  two-thirds  of  the  former  to  one-third  of  the  latter.  In 
cows'  milk  one-sixth  of  the  protein  is  lactalbumin  and  the 
remainder  is  casein.  The  protein  of  human  milk  precipitates 
in  fine  flakes  ;  that  of  cows'  milk,  in  heavy  curds.  The  total 
amount  of  protein  material  also  varies,  being  from  1.5  to  2 
per  cent,  in  human  milk  and,  on  the  average,  3.5  per  cent, 
in  cows'  milk.  The  modification  consists  in  diluting  the 
milk  until  the  protein  is  from  0.6  per  cent,  or  more,  accord- 
ing to  the  age  of  the  infant  and  its  digestive  ability.  In  some 
cases  of  difficult  feeding  the  lactalbumin  and  casein  may  be 
separated  and  added  in  the  required  amounts.  This  is  not, 
however,  usually  necessary.  The  proteins  may  be  prevented 
from  forming  large  curds  by  the  addition  of  lime-water  or  of 
barley-  or  oatmeal-gruel.  With  the  smaller  percentages  this 
is  not  ordinarily  required.  AYhen  necessary,  as  during  ill- 
ness, the  proteins  may  be  predigested. 


78  DISEASES  OF  INFANTS  AND  CHILDREN. 

Sugar. — The  milk-sugar  of  human  milk  is  present  in  a 
very  constant  proportion — from  6  to  7  per  cent.  In  cows' 
milk  it  averages  about  4.5  per  cent.  Diluting  the  milk,  of 
course,  decreases  the  proportion,  and  the  amount  must  be 
made  up  by  adding  either  milk-sugar  or  cane-sugar.  The 
former,  being  that  normally  present  in  the  milk,  seems  the 
most  suitable.  Cane-sugar  has,  however,  many  advocates, 
among  them  being  Jacobi.  Cane-sugar,  owing  to  its  excess- 
ive sweetness,  is  used  in  just  half  the  quantity  of  milk-sugar. 
As  it  is  inexpensive,  it  is  useful  in  practice  among  the  poor. 

During  the  first  few  days  of  life  sugar  may  be  given  in 
the  proportion  of  5  to  5.5  per  cent. ;  from  the  second  week 
to  the  third  month,  6  per  cent. ;  and  from  that  time  until  the 
eleventh  month,  7  per  cent,  may  be  used.  At  the  eleventh 
month  it  may  be  reduced  to  5,  and  a  few  months  later  to 
4.5  per  cent.  There  is  no  advantage  in  giving  over  7  per 
cent.,  and  it  may  give  rise  to  symptoms  of  excessive  sugar- 
feeding. 

Fat. — The  fat  of  human  milk  averages  4  per  cent. ;  that 
of  cows'  milk  is  the  same.  When  the  milk  has  been  diluted 
the  amount  must  either  be  made  up  by  adding  cream  or  by 
using  the  upper  one-third  or  upper  half  of  the  milk  after  the 
cream  has  risen.  It  is  preferable  to  use  fresh  cream  that  has 
risen  by  the  gravity  method  or  the  top-milk  method. 

There  are  objections,  based  on  theoretic  grounds,  to  the 
use  of  centrifugal  cream  ;  these  are  of  less  practical  interest 
in  infant-feeding  than  was  formerly  supposed. 

The  amount  of  fat  to  be  given  varies  with  the  age,  weight, 
and  digestive  ability  of  the  infant.  For  an  average  infant  2 
per  cent,  the  first  week,  2.05  per  cent,  the  second,  and  3 
per  cent,  the  third  week  are  the  amounts  usually  prescribed. 
At  four  months  the  amount  may  be  increased  to  4  per  cent.  ; 
after  that  time  this  amount  must  not  be  exceeded,  or  the 
infant  is  apt  to  develop  indigestion,  with  the  large  whitish 
stools  giving  off  the  characteristic  odor  of  the  fatty  acids. 

Salts. — The  mineral  constituents  of  human  milk  make  up 
about  0.2  per  cent,  of  its  entire  bulk ;  those  of  cow's  milk 
are  three  or  four  times  greater.  These  inorganic  salts  vary  in 
about  the  same  proportion  as  the  proteins.      When  the  milk  is 


INFANT  FEEDING.  79 

modified  for  the  purpose  of  increasing  or  diminishing  the  per- 
centage of  proteins  it  is,  at  the  same  time,  modified  for  the  salts. 

Reaction. — The  reaction  of  human  milk  is  always  alkaline. 
Since  cows'  milk  is  usually  acid  or  neutral,  this  acidity  must 
be  corrected  by  adding  either  5  per  cent,  of  lime-water  or 
sodium  bicarbonate.  The  sodium  salt  is  used  in  the  propor- 
tion of  1  grain  to  the  ounce.  As  the  lime  precipitates  at  the 
higher  temperatures,  when  the  milk  is  to  be  boiled  it  is  better 
to  add  the  bicarbonate.  For  young  infants,  when  there  is  a 
hyperacidity  of  the  stomach  or  acute  illness,  larger  quantities 
than  those  just  mentioned  may  be  used.  Coit  recommends 
the  use  of  potassium  bicarbonate. 

Caloric  Needs  of  Infants. — There  have  been  very 
few  studies  made  in  America  on  this  subject,  but  Camerer, 
Henbner,  Finkelstein,  and  others  have  made  careful  estima- 
tions, chiefly  on  breast-fed  infants. 

Finkelstein  observed  that  the  average  breast-fed  infant 
draws  daily  during  the  first  weeks  of  life  one-fifth  of  its 
body  weight ;  from  the  middle  of  the  first  to  the  end  of  the 
second  quarter  of  the  first  year,  one-sixth  to  one-seventh, 
and  during  the  latter  half  of  the  first  year,  one-eighth  of  its 
body  weight.  Expressed  in  round  numbers  per  kilo  of  body 
weight,  during  the  first  three  months  it  draws  150  cc. ; 
^during  the  second,  somewhat  less,  and  during  the  third  period, 
^20  to  130  cc.  Expressed  in  calories  per  kilo  (Heubner's  en- 
ergy quotient),  the  requirement  during  the  first  three  months  is 
100  per  kilo  (45.4  calories  per  pound),  during  the  second  three 
months  between  100  and  90  (40.9  calories  per  pound),  during 
the  latter  half  of  the  first  year  the  requirement  gradually 
sinks  to  80  or  a  trifle  below  (36.4  calories  per  pound). 

In  regard  to  artificially  fed  children,  Heubner  is  of  the 
opinion  that  the  assimilation  of  cow's  milk  requires  more 
work  than  breast  milk,  and  places  the  energy  quotient  at 
120.  Czerny  and  Keller  at  times  regard  both  breast  and 
cow's  milk  as  about  equal  in  this  respect.  It  is,  perhaps, 
well  in  any  case  to  avoid  excessive  overfeeding. 

The  Determination  of  the  Calorie  Value  of  Modified  Jlill:. — 
Moorehouse  has  given  a  very  simple  method  for  estimating 
the  caloric  value  of  infants'  food  when  the  total  quantity  of 
the  percentage  formula  is  known.     The  method  is  as  follows  : 


80  DISEASES  OF  INFANTS  AND   CHILDREN. 

Reduce  the  twenty-four-hour  amount  to  cubic  centimeters, 
one   ounce   being  equal   to   29.5   cc.      Next,  determine   the 
number  of  grams  of  fat,    sugar,  and  protein  in  the  mixture 
by  multiplying  the  number  of  cubic  centimeters  and   daily 
amount  by  the  percentages   of  fat,  sugar,  and  protein.     The 
calories  from  each  constituent  may  be  determined  by  remem- 
bering that  a  gram  of  fat  furnishes  9.3  calories  and  a  gram  of    \ 
sugar  or  protein  furnishes  4.1  calories.     The  calculation  may 
be  simplified  by  expressing  the  arithmetic  process  by  equations,  \ 
thus  :  Calories  from  fat  equal  Q  XF  X  2.74;  calories  from  s 
sugar  and  protein  equal  Q  X  (S  +  P)  X  1.21.     The  sum  of  \ 


^N 


these  two  values  gives  the  total  calories  furnished  by  the  mix- 
ture, and  this  figure,  divided  by  the  weight  of  the  child  in 
pounds,  gives  the  calories  per  pound  per  day.  In  the  above 
formula  Q  equals  the  twenty-four-hour  amount  in  ounces,  F,  ^ 
S,  and  P,  the  percentages  of  fat,  sugar,  and  protein  expressed  as 
whole  numbers;  for  example,  1  per  cent,  equals  1,  and  not  0.01. 
Fraley's  Method. — This  is  not  strictly  accurate,  but  suffi- 
ciently so  for  all  practical  purposes.  In  calculating  milk 
mixtures  he  uses  the  following  formula  : 

2F  +  P  +  S  X  1|  =  Calories, 
or  twice  the  fat  percentage  plus  the  protein  percentage  andj 
the  sugar  percentage  multiplied  by  1J  times  the  total  quan- 
tity in  ounces  gives  approximately  the  number  of  calories. 

MILK  MODIFICATION. 

(Methods  of  Practical  Value  in  Modifying  Milk.) 
There  are  a  number  of  methods  of  milk  modification  that 
may  be  used  with  good  results  in  the  artificial  feeding  of 
infants.  A  practical  knowledge  of  these  methods  is  a  de- 
sideratum in  the  rearing  of  bottle-fed  infants.  Those  most 
in  use  are  : 

1.  Laboratory  feeding. 

2.  Top-milk  method. 

3.  Materna  graduate. 

4.  According  to  Maynard  Ladd's  table  (after  Rotch). 

5.  Baner's  method. 

6.  According  to  Louis  Starr's  table. 
1.  laboratory  Feeding. — In  cities  the  best  substitute 

for  breast-feeding  is  furnished  by  milk  laboratories,  where 


INFANT  FEEDING. 


81 


modifications  are  made  according  to  the  physician's  prescrip- 
tion. The  Walker-Gordon  laboratories,  now  established  in 
many  cities,  supply  an  ideally  clean  milk,  unsterilized,  pas- 
teurized, or  sterilized  at  any  temperature  desired.  The  milk 
is  supplied  in  nursing-bottles,  each  bottle  holding  enough  for 
one  feeding  and  being  ready  for  use.  Beyond  warming  the 
bottle  and  putting  on  a  nipple  no  further  preparation  is 
necessary.  In  winter  the  milk  is  delivered  in  baskets,  and 
in  summer  in  small  refrigerators.  When  economy  must  be 
practised,  the  milk  may  be  obtained  in  larger  jars  and 
divided  into  the  requisite  number  of  feedings  by  the  mother 
or  nurse.  Blank  forms  on  which  to  write  prescriptions  arc 
furnished  physician?.  The  following  is  an  example  of  such 
a  prescription  : 

^ 


Per  Cent. 


Fat 4 

Milk-sugar  ....    7 

Proteins 2 

Lime-water .   .   .   .    5 
Other  Diluent     •   • 
Heated  at  167°  F. 


Number  of 
feedings  ■   • 

Amount  at 
each  feeding 

Infant's  age 

Infant's  iv  eight 


7  ounces. 


Ordered  for. 


Date, 


Signature, 


190 


M.   D. 


These  prescriptions  are  filled  at  the  laboratory  by  mixing 
together  milk,  cream,  standard  sugar  solutions,  and  water  in 
the  proper  proportions.  In  some  cases  a  16  per  cent,  gravity 
cream  is  used,  and  in  others  a  20  per  cent,  centrifugal  cream. 
Other  things  being  equal,  it  is  more  desirable  on  theoretic 
grounds  to  use  gravity  cream. 

Sometimes  the  casein  and  whey  are  separated  by  using 
rennin  or  Fairchild's  Essence  of  Pepsin,  and  so  more  diges- 
tible mixtures  made.  The  whey  must  be  heated  to  150°  F. 
6 


82 


DISEASES  OF  INFANTS  AND   CHILDREN 


for  five  minutes  before  being  added  to  the  milk  to  destroy 
the  enzyme  or  it  will  cause  coagulation. 

The  Walker-Gordon  Company  supply  the  following  table  : 

Theoretical  Bad s  for  Feeding  a  Healthy  Infant. 


Proteins  if 

split. 

tf'O  & 

%%2 

•d-* 

Age. 

Fat. 

CO 

a 

CO 

,  j 

&  a  d 

•r-    CO 

be 

o 

P4 

Oj  C<0 
co  O 

u 

Amou 
each 
ing  i 

Inten 

twee 

ingii 

No.  of 
ings 
hour 

1.00 
1.50 

4.00 
4.50 

0.25 
0.25 

0.25 
0.50 

0.25 
0.25 

Vs-% 

i-iH 

24-18 

At  term 

2.00 

5.00 

0.50 

0.50 

0.25 

1 

2 

10 

End  of  second  week    . 

2.50 

5.50 

0.50 

0.50 

0.25 

±a 

2 

10 

End  of  third  week    .   . 

3.00 

6.00 

0.75 

0.75 

0.25 

o 

2 

9 

End  of  fourth  week  .  . 

3.50 

6.50 

1.00 

0.75 

0.50 

PA 

2 

8 

End  of  sixth  week  .  . 

4.00 

7.00 

1.00 

0.90 

0.60 

3 

214 

7 

End  of  eighth  week    . 

4.00 

7.00 

1.25 

0.90 

0.75 

3^ 

iy2 

7 

End  of  twelfth  week   . 

4.00 

7.00 

1.50 

0.90 

1.00 

4 

ixA 

6 

End  of  fourth  month   . 

4.00 

7.00 

1.50 

0.75 

1.25 

^A 

PA 

6 

End  of  fifth  month  .   . 

4.00 

7.00 

1.75 

&A 

3 

6 

End  of  sixth  month     . 

4.00 

7.00 

2.00 

6 

3 

6 

End  of  eighth  month    . 

4.00 

7.00 

2.50 

7 

3 

6 

End  of  ninth  month    . 

4.00 

7.00 

3.00 

8 

3 

6 

End  of  tenth  month 

4.00 

6.00 

3.00 

8 

3 

6 

End  of  eleventh  month 

4.00 

5.00 

3.00 

10 

3 

5 

End  of  twelfth  month 

|  4.00 

4.75 

3.50 

10 

3 

5 

In  most  cases  whey  mixtures  are  unnecessary.  In  acute 
illness  or  when  there  is  decided  lowering  of  the  protein  diges- 
tive power  they  may  be  of  great  service. 

The  percentage  of  fat,  protein,  and  sugar  required  by  an 
infant  of  any  given  age  must  be  borne  in  mind  if  one  is  to 
use  any  method  of  percentage  feeding.  The  following  sched- 
ule will  be  found  useful  as  an  aid  to  the  memory.  The  figures 
for  intermediate  ages  are  easily  calculated  : 

Schedule  for  Average  Infants. 


Age. 

Percentage. 

Average  quantity  for 
one  feeding. 

Number 

of 
feedings 
24  hours. 

Interval 

Fat. 

Sugar. 

Protein. 

Ounces. 

Grams. 

by  day. 

Premature  infants  .   . 
First  to  second  day    . 
Second  to  eighth  day 

Third  week 

Second  month  .... 
Third  month     .... 
Fourth  month  .... 

Fifth  month 

Sixth  to  tenth  month 
Eleventh  month  .   .   . 
Twelfth  month    .  .   . 
Later 

1.0 

2.6 
2.5 
3.0 
3.0 
3.5 
3.5 
4.0 
4.0 
4.0 
4.0 

4.0 
5.0 
6.0 
6.0 
6.0 
6.5 
7.0 
7.0 
7.0 
5.0 
5.0 
4.5 

0.25 

0.50 
0.75 
1.00 
1.25 
1.50 
1.75 
2.00 
2.50 
3.00 
3.50 

2 
3 

4 
5 
7 
8 
9 
9 

10-20 
30-45 

45 

60 

90 
110 
125 
160 
220 
250 
280 
300 

12-20 
4-6 
10 
10 
9 
8 
7 
7 
6 
5 
5 
5 

1-1£  hrs. 
6-4      " 

2        " 

2 

2*      " 

3 

3 

3 

3 

4 

4 

4        " 

INFANT  FEEDING. 


83 


The  quantity  should  be  increased  half  an  ounce  or  an 
ounce  at  a  time.  Later,  as  the  child's  appetite  grows  stronger 
— that  is,  when  he  seems  dissatisfied  after  his  bottle — the 
quality  is  raised.  The  fat  may  usually  be  increased  0.5  per 
cent,  at  a  time;  the  sugar,  0.5  to  1  per  cent,  at  a  time  ;  the 
proteins,  from  0.1  to  0.25  per  cent,  at  a  time.  Strong, 
healthy,  large  babies  require  more  and  richer  milk  than  those 
of  frailer  constitution. 

Ssnitkin,  of  St.  Petersburg,  has  estimated  the  amount  to 
be  fed  to  a  child  according  to  the  weight.  He  ascertained 
that  a  baby's  stomach  held  about  one-hundredth  of  its  weight 
at  birth,  and  that  the  increase  amounted  to  about  a  gram  a 
day.  By  taking  one-hundredth 
of  the  initial  weight  at  birth  and 
adding  a  gram  for  each  day  the 
average  amount  required  for  each 
feeding  is  ascertained. 

2.  Top-milk  Method. — 
Many  methods  have  been  de- 
vised for  obtaining  the  desired 
percentage  from  milk  as  it  is 
used  in  the  home. 

Holt's  top-milk  method  is  a 
very  satisfactory  one.  Care 
should  be  taken  to  secure  good, 
fresh  cows'  milk. 

The  top-milk  method  con- 
sists in  using  the  mixture  of 
cream  and  milk  in  the  upper  one-third  or  upper  one-half  of  a 
jar  of  milk  that  has  been  allowed  to  stand  for  some  time. 
Later,  the  whole  milk  may  be  used.  This  method  works 
satisfactorily  only  when  the  milk  is  bottled  soon  after  milk- 
ing, before  the  cream  has  separated.  For  those  who  cannot 
obtain  such  milk  the  necessary  mixture  of  cream  and  milk 
may  be  made  as  indicated  in  the  table.  The  top  layer  of 
cream  may  be  removed  from  the  bottled  milk  with  a  spoon  ; 
the  remainder,  by  means  of  a  small  dipper;  for  this  purpose 
a  Chapin  milk-dipper,  which  may  be  obtained  at  any  drug- 


Fig.  23.— The  Chapin  dipper. 


84  DISEASES  OF  INFANTS  AND   CHILDREN. 

store,  will  be  found  very  useful.  Another  method  is  to  use 
a  siphon.  The  plan  of  pouring  off  the  upper  third  is  not 
nearly  so  reliable.  After  it  has  been  removed,  and  before 
the  required  portion  is  taken  out,  the  entire  upper  one-third 
or  one-half,  as  the  case  may  be,  should  be  thoroughly  mixed. 

The  following  tables  require  no  explanation.  When  de- 
sired the  percentage  of  lime-water  may  be  increased,  or  it 
may  be  replaced  by  sodium  bicarbonate,  one  grain  or  more  per 
ounce,  if  the  milk  is  to  be  boiled.  If  the  quantity  required 
exceeds  twenty  ounces  the  smaller  supplementary  tables  may 
be  used,  or  the  quantity  may  easily  be  calculated  by  adding 
an  additional  one-fourth  to  each  item  for  twenty-five  ounces, 
or  one-half  more  for  thirty  ounces,  etc. 

The  sugar  may  be  measured  by  means  of  a  pill-box  hold- 
ing exactly  an  ounce,  or  very  conveniently  by  allowing  two 
and  one  half  level  tablespoonfuls  of  milk-sugar  to  the  ounce. 
When  cane-sugar  is  used  only  one-half  the  quantity  is  re- 
quired. Dry  measure  of  sugar  is  just  twice  that  of  weigh- 
ing. Thus,  one  ounce  of  sugar  by  weight  would  measure 
two  ounces  in  a  measuring  glass. 

The  following  formulas  have  been  taken  from  Holt : l 

First  Series  of  Formulas — Fat  to  Proteins,  3:1. 

Primary  Formula. — Ten  per  cent,  milk — fat,  10  percent. ; 
sugar,  4.3  per  cent.  ;  proteins,  3.3  per  cent.  Obtained — (1) 
as  upper  one-third  of  bottled  milk  or  (2)  equal  parts  of  milk 
and  16  per  cent,  cream. 

Derived  formulas,  giving  quantities  for  20-ounce  mixtures  : 


f  Milk-sugar    .     1  oz. 
1.  -j  Lime-water  .     1  oz.  \  with  2  oz.  10  p.c.  milk 


(  Water,  q.s.  ad.  20  oz 

"2.  "         "  "  «     3  oz. 

3.  "         "  "  "     4oz. 

4.  "         "  "  "     5oz. 

5.  "         "  "  "     6oz. 

6.  "        "  "  "7  oz. 

1  Diseases  of  Infancy  and  Childhood,  pp.  189, 191,  192. 


Fat 

Sugar 

Proteins 

per  ct. 

per  ct. 

per  ct. 

1.00 

5.50 

0.33 

1.50 

5.50 

0.50 

2.00 

6.00 

0.66 

2.50 

6.00 

0.83 

3.00 

6.00 

1.00 

3.50 

6.50 

1.16 

INFANT  FEEDING.  85 

Table  Giving  in  a  Condensed  Form  the  Quantities  Usually  Re- 
quired for  Obtaining  the  Different  Fat-percentages. 

ABCDEFGHIJKL   M   N   O 

Tpe°rbcent  ^  }  °-50    L0    L5    2,°    2'°    2'5    2Si    "7;3    3-°    30    :'°    s-25    :;  "'    3'7    40 
^nSfJ  f00d4  0.20  20.0  20.0  20.0  25.0  25.0  28.0  28.00  30.0  33.0  36.0  36.00  37.0  38.0  40.0 

^^n-'^f.lfhi-O.lO    2.0    2.0    4.0    5.0    6.0    7.0    8.00    9.0  10.0  11.0  12.00  13.0  14.0  16.0 

III  1  IK,  OUIlCcS  ) 

Proteins :  The  percentage  in  each  case  will  be  one-third  fat. 

Sugar:  1  ounce  in  20,  or  1  tablespoonful  in  8  ounces,  gives  5.5  per  cent. 
for  the  lower  and  6.5  for  the  higher  formulas. 

Lime-water :  1  part  to  20  of  the  food,  the  average  required. 

Water:  Sufficient  to  be  added  to  the  foregoing  ingredients  to  bring  the 
total  to  the  number  of  ounces  specified  ;  in  part  of  this  water  the  milk-sugar 
is  dissolved.  Barley-water  or  any  other  dilutent  may  be  added  in  the  same 
manner. 

Second  Series  of  Formulas — Fat  to  Proteins,  2:1. 

Primary  Formula. — Seven  per  cent,  milk — fat,  7  percent.  ; 
sugar,  4.4  per  cent. ;  proteins,  3.5  per  cent,  Obtained — (1) 
as  upper  one-half  of  bottled  milk,  or  (2)  by  using  3  parts  of 
milk  and  1  part  of  16  per  cent,  cream. 

Derived  formulas,  giving  quantities  for  20-ounce  mixtures  : 


p.c.  milk 


T  Milk-sugar    . 

1 

oz. 

) 

1. 

\  Lime-water   . 

1 

oz. 

V  with  3  oz.  7 

1  Water, 

q.s.  ad. 

20 

oz.  . 

) 

2. 

a 

a 

It 

a 

4  oz. 

3] 

a 

u 

u 

a 

5  oz. 

4. 

a 

if 

a 

u 

6  oz. 

5. 

it 

il 

a 

it 

7  oz. 

6. 

a 

(I 

u 

a 

8oz. 

7. 

a 

(( 

a 

a 

9  oz. 

8. 

a 

a 

a 

n 

10  oz. 

(  Milk-sugar    . 

3 

4 

OZ.  " 

1 

9. 

\  Lime-water    . 

1 

oz. 

" 

12  oz. 

Fat 

Sugar 

Proteins 

per  ct. 

per  ct. 

per  ct.  ■ 

.    .  1.00 

5.50 

0.50 

.    .  1.40 

5.75 

0.70 

.    .  1.75 

6.00 

0.87 

.    .  2.10 

6.00 

1.05 

.    .  2.50 

6.50 

1.25 

.    .  2.80 

6.50 

1.40 

.    .  3.15 

7.00 

1.55 

.    .  3.50 

7.00 

1.75 

4.00         7.00         2.00 


(  Water,  q.s.  ad.  20  oz. 


Table  Giving  in  a  Condensed  Form  the  Quantities  Usually  Re- 
quired for  Obtaining  the  Different  Fat-percentages. 

ABCDEF         G        HIJKLM 
To  obtain  fat.  per  cent.    1.0    1.0    1.4    1.8    2.0    2.33    2.75    2.75    3.1    3.5    35    4.0    4.0 
For  total  food,  ounces  .  20.0  30.0  30.0  33.0  33.0  36.00  36.00  40.00  40.0  40.0  44.0  44.0  48.0 
Take  7  per  ct.  milk,  ozs.    3.0    4.0    6.0    8.0  10.0  12.00  14.00  16.00  18.0  20.0  22.0  2o.O  28.0 

To  obtain  the  exact  fat-percentages  take  one-third  the  number  of  ounces 
of  top-milk  in  a  20-ounce  mixture  and  add  0.15  to  the  result.  In  practice 
this  slight  error  may  be  disregarded. 


86  DISEASES  OF  INFANTS  AND   CHILDREN. 

Proteins :  The  percentage  in  each  case  will  equal  one-half  of  the  fat. 

Sugar:  1  ounce  in  20,  or  1  even  tablespoonful  in  8  ounces,  until  the 
food  becomes  half  milk ;  after  that  1  ounce  in  25,  or  1  even  tablespoonful 
to  each  10  ounces  of  the  food,  will  give  the  proper  amount. 

Lime-water :  Usually  in  the  proportion  of  1  part  to  20  of  the  total  food. 

Water  or  other  diluents:  Sufficient  to  be  added  to  the  foregoing  ingre- 
dients to  make  the  total  number  of  ounces  specified ;  in  part  of  this  the 
sugar  is  dissolved. 

Third  Series  of  Formulas — Fat  to  Proteins,  8:7. 

Primary  Formula. — Plain  milk — fat,  5  per  cent. ;  sugar, 
4.5  per  cent. ;  proteins,  3.5  per  cent. 

Derived  formulas,  giving  quantities  for  20-ounce  mixtures  : 


1. 

f  Milk-sugar    .    1  oz.  ' 
-j  Lime-water   .    1  oz. 

\  with  5  oz. 

plain 

milk   . 

Fat 
per  ct. 

.  1.00 

Sugar 
per  ct. 

6.00 

Proteins 
per  ct. 

0.87 

2. 

(  Water,  q.s.  ad.  20  oz. , 

a.           a                  a 

i 

"     6  oz. 

it 

ti 

.  1.20 

6.00 

1.00 

3. 

it           a                  it 

"     8  oz. 

a 

a 

.  1.60 

6.50 

1.40 

4. 

u          a                 tt 

"  10  oz. 

a 

a 

.  2.00 

7.00 

1.75 

5. 

f  Milk-sugar     .    J  oz. " 
-j  Lime-water    .    ^  oz. 

1     "  12  oz. 

a 

a 

.  2.40 

5.00 

2.10 

6. 

(  Water,  q.s.  ad.  20  oz. , 

it           a                   a 

1 

"  14  oz. 

a 

a 

.  2.80 

5.50 

2.50 

7. 

a           a                  a 

"  16  oz. 

a 

a 

.  3.20 

5.50 

2.80 

Table  Giving  Quantities  of  16  per  cent  Milk  Required  for  Ob- 
taining Formulas  with  High  Fat  and  Low  Proteins. 

A         "R        r1        T)        "R        Th1        C*         TT        T        T       "K* 

To  obtain  fat,  per  cent 1.6    1.6    2.0    2.5    3.0    3.0    3.0    3.5    3.5    4.0    4.0 

For  total  food,  ounces 20.0  30.0  30.0  32.0  32  0  37.0  42.0  36.0  40.0  40.0  44.0 

Take  16  per  cent.  milk,  ounces  ...    2.0    3.0    4.0    5.0    6.0    7.0    8.0    8.0    9.0  10.0  11. 

Proteins  in  all  cases  will  be  one-fifth  the  fat. 

Sugar :  1  even  tablespoonful  for  each  8  ounces  will  give  5.5  per  cent,  for 
the  lower  formulas  (A,  B,  C,  etc. )  and  6  per  cent,  for  the  higher  formulas 
(G,  H,  I,  etc.). 

Lime-water :  1  ounce  to  20  ounces  of  the  food  will  give  5  per  cent. 

3.  Holt's  Percentage  Milk  Method. — Holt  has  de- 
vised another  method  of  modifying  milk  which  is  very  use- 
ful. The  following  method  at  first  sight  looks  very  compli- 
cated, but  it  is  not,  and  it  permits  of  great  numbers  of 
reasonably  exact  formulae.  The  first  step  is  to  obtain  milks  con- 
taining definite  amounts  of  fat  from  7  per  cent,  down  to  1  per 
cent.  Ordinary  market  milk  from  mixed  herds  averages  4 
per  cent,  milk,  from  Jerseys  and  Alderneys  5  per  cent,  or  more. 


INFANT  FEEDING.  87 

Uniform  results  may  be  obtained  by  having  patients  use 
milk  from  one  dairy,  or  by  having  them  buy  milk  containing 
a  certain  percentage  of  fat  from  milk  laboratories. 

For  convenience  the  formulae  are  calculated  for  20-ounce 
mixtures. 

Every  ounce  of  7  per  cent,  milk  in  20-ounce  mixture  has 
one-twentieth  of  7  or  0.35  per  cent.  fat. 

Every  ounce  of  6  per  cent,  milk  in  20-ounce  mixture  has 
one-twentieth  of  6  or  0.30  per  cent.  fat. 

Every  ounce  of  5  per  cent,  milk  in  20-ounce  mixture  has 
one-twentieth  of  5  in  0.25  per  cent.  fat. 

Every  ounce  of  1  per  cent,  milk  in  20-ounce  mixture  has 
one-twentieth  of  0.05  per  cent.  fat. 

The  variations  in  protein  and  sugar  used  may  be  con- 
sidered. Four  per  cent,  milk  contains  4.50  per  cent,  sugar 
and  3.50  per  cent,  protein,  so  each  ounce  of  4  per  cent,  milk 
in  any  of  the  formulae  in  a  20-ounce  mixture  will  contain  one- 
twentieth  or  0.225  per  cent,  sugar  and  0.175  per  cent,  protein. 

The  tables  from  Holt  (p.  88)  show  the  variations  that 
may  easily  be  obtained.  To  raise  the  fat  without  the  protein 
use  a  milk  of  a  higher  fat  percentage.  To  raise  the  protein 
and  not  the  fat  use  more  ounces  of  the  same  milk  or  even  of 
a  weaker  one  if  need  be. 

The  necessary  sugar  is  added,  remembering  that  each  ounce 
of  milk-sugar  by  weight  in  a  20-ounce  mixture  increases  the 
sugar  6  per  cent.,  or  each  ounce  by  volume  about  3  per  cent., 
and  that  each  level  tablespoonful  in  a  20-ounce  mixture  in- 
creased the  sugar  about  1.75  per  cent. 

These  formulae  give  rather  low  fat  percentages,  but  other- 
wise are  sufficiently  elastic  to  suit  all  needs.  As  a  matter 
of  fact,  comparatively  few  variations  are  required  except  in 
difficult  cases. 

4.  Materna  Graduate  Method. — The  very  simple  and 
useful  apparatus  known  as  the  Estrans  Materna  Graduate  is 
of  great  value  where  one  cannot  secure  intelligent  coopera- 
tion in  the  home,  and  also  where  there  are  no  facilities  for 
milk  preparation.  AVith  its  six  formulas,  however,  it  is  not 
adaptable  to  all  cases,  some  infants  being  totally  incapable  of 
taking  the  step  from  one  formula  to  another. 


88 


DISEASES  OF  INFANTS  AND   CHILDREN. 


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IXFA  NT  FEEDING. 


89 


The  apparatus  consists  of  a  glass  jar  with  a  lip  and  seven 
panels,  and  a  capacity  of  sixteen  ounces.  One  of  the  panels 
exhibits  an  ordinary  ounce  graduation  ;  the  other  six  panels 
present  six  different   formulas  for  the  modification  of  cows* 


Fig.  24.— The  "Materna"  glass  (De  Lee). 

milk,  each  formula  being  so  arranged  as  to  keep  pace  with 
the  infant's  growth.     (See  Table,  next  page.) 

Having  decided  which  formula  is  to  be  used,  the  panel 
containing  that  formula  is  the  only  one  to  be  followed. 

The  quantity  desired  for  twenty-four  hours  is  next  to  be  con- 
sidered, and  the  apparatus  filled — once  if  16  ounces  or  less  are 
required  for  the  twenty-four  hours;  twice  if  from  16  to  32 
ounces  are  required  for  the  twenty-four  hours  ;  three  times  if 
from  32  to  48  ounces  are  required  for  the  twenty-four  hours. 

Fat  ....  2  per  ct.  2£  per  et.  3  per  ct.  34  per  ct.  4  per  ct.  oh  per  et. 

Sugar 6       "       6"       "       6       «       7        "        7       "       3£      " 

Protein    .    ...  0.6   "       0.8     "       1       "       14      "        2       "       2\      " 


90 


DISEASES  OF  INFANTS  AND   CHILDREN. 


Modification  According  to   Growth. 


Milk parts 

Cream " 

Lirne-water  ....     " 

Water " 

Milk-sugar    ....     " 


^ 

o 

-t^> 

,d 

c 

M    . 

. 

5^ 

ta 
O 

> 

<X> 

(XI 

O    ; 

CD+5 

.s 

+j  +i 

-e^J 

-M^ 

O  0) 

rH    CD 

Olr^ 

^  o 

IK 

1% 

2 

4K 

6 

IK 

1% 

2 

2 

2 

l 

1 

34 

8% 

% 

12^ 

UK 

UK 

?K 

1 

1 

i 

1 

IK 

Milk    ....   parts 
Cream     ...       " 
Barley-gruel       " 
Granulated  sugar, 
parts 


~  o 

.5  a 


1 


Maynard  Ladd's   Table. 


Prescriptions  call- 

Fat free  milk  in  ounces 

ing  for  a  mixture 

Cream  m  ounces. 

used  with 

3reams 

,  of- 

of  20  ounces. 

a 

CD 

0 

u 

+^° 

4-5 

^ 

-t> 

u  n 

-t-"  "S 

a. 

c 

a 

a 

fl 

c 

-u     • 

oS    . 

<?ru 

*  s 

<D 

CD 

CD 

CD 

0) 

CD 

CD 

CD 

*  m 

btj^ 

a 

>  o 

O 

O 

O 

CD 

CD 

CD 

S-i 

*H 

CD 
Fh 

"f  ° 

d| 

P   35 

CO 

o3 
bo 

o 

0) 
ft 

CD 
ft 

CD 
ft 

CD 

ft 

CD 

ft 

CD 

ft 

CD 
ft 

CD 

ft 

CD  -h 
3^ 

o  ° 

»  CD 

N 

0 

ft 

3 

o 

CI 

I— 1 

.-1 

O 
CM 

o 

r-l 

CM 

rH 

i-H 

O 
CM 

1-^ 

pq 

3 

0.50 

5.00 

2.00 

5 

1 

4 

3 

4 

1 

94 

9* 

9* 

9f 

1 

84 

14 

0.75 

6.00 

1.00 

5 

1* 

14 

1 

3 

4 

3* 

3f 

4 

44 

1 

14 

24 

1.00 

5.00 

0.75 

5 

2 

H 

1* 

1 

2 

2* 

91 

3 

1 

15 

2 

1.50 

4.00 

0.50 

5 

(*) 

2* 

2 

i* 

(l) 

i 

4 

3 

4 

14 

1 

164 

1* 

2.00 

5.00 

0.75 

5 

4 

3 

2* 

1* 

0 

1 

1* 

24 

1 

15 

2 

2.00 

5.50 

1.00 

5 

4 

3 

2* 

if 

l* 

2i 

2f 

3* 

1 

13* 

24 

2.50 

6.00 

1.00 

5 

5 

4 

84 

2* 

0 

1* 

24 

3 

1 

14 

2* 

3.00 

6.00 

0.50 

5 

n 

n 

Sf 

3 

ft 

n 

0 

3. 

4 

1 

154 

if 

3.00 

6.00 

0.75 

5 

C1) 

5 

3f 

3 

0 

14 

2 

1 

14 

2* 

3.00 

6.00 

1.00 

5 

(M 

4* 

3* 

2f 

(') 

3 

4 

if 

2* 

1 

13* 

24 

3.50 

6.50 

1.00 

5 

n 

5* 

4* 

3* 

I1) 

0 

l 

2 

1 

13* 

2* 

3.50 

6.50 

1.50 

5 

7 

5* 

4* 

3* 

l 

9A- 

3* 

4* 

1 

11 

2* 

3.00 

7.00 

1.00 

5 

n 

4f 

8} 

2f 

(') 

3 

4 

13- 

x4 

24 

1 

13* 

24 

3.00 

7.00 

1.50 

5 

6 

4f 

8} 

2f 

2 

34 

44 

54 

1 

11 

2* 

3.00 

7.00 

2.00 

5 

6 

4f 

34 

2f 

4* 

5f 

6} 

74 

1 

84 

2i 

4.00 

7.00 

1.00 

5 

(x) 

H 

5 

3* 

(x) 

(l) 

i 

If 

1 

13* 

24 

4.00 

7.00 

1.50 

5 

8 

64 

5 

3* 

0 

l3- 

x4 

3 

44 

1 

11 

24 

4.00 

7.00 

2.00 

5 

8 

64 

5 

3f 

2* 

4* 

5* 

6| 

1    . 

8* 

2* 

4.00 

7.00 

2.50 

5 

8 

64 

5 

34 

5 

6f 

8 

94 

1 

6 

2 

4.00 

7.00 

3.00 

5 

8 

64 

5 

34 

7* 

9* 

10* 

llf 

1 

3* 

2 

4.00 

6.00 

3.00 

5 

8 

6* 

5 

8f 

7* 

»* 

10* 

11* 

1 

3* 

14 

4.00 

5.00 

3.00 

5 

8 

64 

5 

n 

7* 

94 

10* 

114 

1 

3* 

l 

4.00 

5.00 

3.50 

5 

8 

6i 

5 

3| 

10 

11| 

13 

144 

1 

1 

i 

(x)  indicates  that  the  combination  is  impossible  with  the  percentage  of 
cream  given. 


INFANT  FEEDING.  91 

5.  Maynard  I,add's  Table.1 — Another  method  of 
modifying  milk  is  according  to  Maynard  Ladd's  table  (pre- 
ceding page).  In  this  the  quantities  have  been  estimated. 
This  method  is  useful  in  hospitals  where  there  is  a  milk 
laboratory.  In  general  practice  it  is  of  slight  value,  for  it 
necessitates  memorizing  a  lengthy  table,  or  carrying  it  about, 
both  of  which  methods  are  open  to  objection. 

6.  Baner's  Method. — Many  attempts  have  been  made 
from  time  to  time  to  compute  a  table  of  equations  from  which 
the  quantities  of  milk,  cream,  etc.,  may  be  determined  for 
any  given  mixture  ;  the  simplest  of  these  is  that  of  Baner  ; 2 

=  F. 


Quantity  desired  (in  ounces) 

Desired  percentage  of  fat 

Desired  percentage  of  sugar  =S. 

Desired  percentage  of  protein  =  P 


=  P. 

To  find  in  ounces — 

Cream  (16  per  cent.)  =    o  x  (F~  P">' 

Milk  =-22LP_g 

4 

Water  =Q-{C+M). 

S-PxQ 

Dry  milk-sugar  =      100 

Example. — Suppose  it  is  desired  to  make  40  ounces  of  a  4 
per  cent,  fat,  7  per  cent,  sugar,  2  per  cent,  protein  mixture. 
By  substituting  the  figures  in  the  equations  above  we  have — 

Cream  =  —  x  2  —  61  ounces. 

12 

Milk  =  ^^  -  6|  =  13£  ounces. 

4 

Water  =  40  -  20  =  20  ounces. 

c                     5x40     o 
Sugar  = =  2  ounces. 

&  100 

7.  I/OUis  Stands  Table. — This  is  a  frequently  used 
guide  to  milk-prescribing.  It  may  be  employed  as  a  basis 
for  modification  by  those  who  object  to  the  percentage  method. 
The  latter  method,  however,  once  mastered,  will  be  found  more 
satisfactory  for  general  purposes. 

1  Taken  from  Rotch's  Pediatrics.       2  New  York  Med.  Jour.,  Mar.  12, 1898. 


92 


DISEASES  OE  INFANTS  AND   CHILDREN. 


Louis  Starr's  Table  of  Ingredients,  Hours,  and  Intervals  of  Feed- 
ing, and  Total  quantity  of  Food  for  a  Healthy  Artificially 
Fed  Infant  from  Birth  to  the  End  of  the  Seventh  Month.1 


i 

u 

Hours  for 

•vals 

f 

ing. 

Total 

Age. 

oj 

V 

X 

-1-3 

feeding. 

3cc 

quantity. 

2 

g* 

02 

fS 

Hours 

f    5  A.  M.  to 

1 

| 

I  11  p.  m.  ; 

During  1st  wk 

foij 

fSiij 

gr.xx 

fSiij 

■{  sometimes 
|  1  a.  M.  and 

[  3  A.  M. 

1-2 
j 

fsxij 

From    2d  to) 
6th  week  .  J 

f5ij 

f3SS 

gr.xx 

a  pinch 

f3j 

(5  A.  M.  to 
(.11  P.  M. 

\* 

fSxvij 

From  6th  wk.  "| 
to   end  of  >- 

fSss 

f5x 

5ss 

a  pinch 

f3x 

(5  A.  M.  tO 
\11  P.  M. 

}2 

fSxxx 

2d    month  J 

From    3d  to  \ 
6th  month  J 

fSss 

fSij 

5j 

a  pinch 

fsiss 

(5  A.  M.  tO 
1 10.30  P.M. 

}VA 

fSxxxij 

During     6th"] 

/7  a.  m.  to 

(10  P.  M. 

}3 

and        7th  > 

fSss 

fSiiiss 

5j 

a  pinch 

fSij 

fgxxxvj 

months     .  J 

Throughout  the  eighth  and  ninth  months  five  meals  a  day 
will  be  sufficient,  each  meal  composed  of : 

Milk fgvj 

Cream fjfss 

Milk-sugar •    oj 

Water f^iss 

This  allows  40  fluidounces  of  food  a  day. 

Malted  Gruels. — Malted  gruels  are  advocated  by  some, 
especially  in  preparing  milk  for  infants  with  weak  digestion. 
They  are  prepared  in  the  following  manner  :  A  tablespoonful 
of  barley  flour,  or  of  any  other  flour  desired,  is  boiled  in  a 
little  more  than  a  pint  of  water  for  fifteen  minutes.  As  soon 
as  it  has  cooled,  a  teaspoonful  of  good  malt  extract  or  a 
teaspoonful  of  diastase  is  added.  This  mixture  is  stirred 
thoroughly,  and  may  then  be  used  in  the  place  of  ordinary 
barley-water.  Diastase  preparations  are  made  by  most  of 
the  leading  manufacturing  chemists.  Diastoid,  maltine,  and 
dyazyme  are  preparations  of  this  class.  The  thick  malt  ex- 
tracts are  sometimes  given  to  infants  just  before  a  feeding. 
Of  these,  several  doses  may  be  given  daily  for  indigestion 
and  constipation. 

1  From  Diseases  of  the  Digestive  Organs  in  Children,  p.  24. 


INFANT  FEEDING.  93 

Farinaceous  Gruels. — In  the  methods  of  feeding  just 

described  the  addition  of  farinaceous  gruels — i.  e.,  barley,  oat- 
meal, arrow-root,  rice,  etc. — to  some  of  the  foods  has  been 
recommended  by  certain  observers.  That  such  addition  to 
the  infant's  dietary  during  the  first  year  is  advisable  is  a 
question  that  has  not  been  fully  decided.  When  deemed 
necessary,  it  is  probably  best  to  begin  the  addition  of  a  starchy 
gruel  to  the  milk  at  about  the  eighth  or  ninth  month  in  nor- 
mal infants.  In  those  infants  who  experience  difficulty  in 
digesting  the  proteins,  and  for  the  purpose  of  preventing  co- 
agulation of  the  milk  into  large  clots,  the  addition  may  be 
made  earlier.  It  is  well  to  begin  by  adding  a  half-ounce  or 
an  ounce  for  each  feeding,  and,  as  the  infant's  starch-digest- 
ing power  increases,  to  increase  this  amount  proportionately. 

Condensed  Milk. — This  is  most  useful  in  many  cases 
as  a  temporary  expedient,  especially  where  children  are  not 
gaining,  and  those  that  have  been  fed  on  too  high  fat  and 
protein.  It  should  be  used  in  dilutions  of  1  in  16,  1  in  12, 
and  1  in  8.  It  should  be  measured  in  a  measuring  glass, 
otherwise  too  much  will  be  used.  It  may  be  diluted  with 
plain  boiled  water  or,  if  desired,  with  a  thin  cereal  gruel. 
Cream  may  be  added  later,  or  olive  oil  may  be  given  in 
addition.  Orange  juice  should  be  given  every  other  day  or  every 
day  as  an  antiscorbutic.  If  condensed  milk  feeding  is  con- 
tinued too  long,  anemia,  scurvy,  or  rickets  is  liable  to  develop. 

Buttermilk. — Real  buttermilk  may  be  used,  which  has 
the  advantage  of  having  a  low  fat  and  sugar  content  and 
the  presence  of  large  numbers  of  lactic-acid  bacilli.  If  de- 
sired, whole  milk,  which  has  been  soured  by  the  addition  of 
lactic-acid  bacilli,  may  be  used.  It  may  be  diluted  with 
water  or  cereal  gruels  the  same  as  whole  milk.  It  is  very 
useful  in  diarrheas,  especially  where  abnormal  bacteria  are 
present  in  intestinal  indigestion  and  other  difficult  cases. 

Albumin  Milk.1 — This  is  made  from  curd  and  butter- 
milk. It  is  useful  in  diarrhea,  indigestion,  and  certain  forms 
of  nutritional  disturbances.  It  should  be  carefully  studied 
before  being  used.  (See  Friedenwald  and  Ruhrah,  "  Diet  in 
Health  and  Disease,"  Fourth  Edition.) 

1  Hess,  American  Journal  of  Diseases  of  Children,  December,  1911,  vol.  iv., 
p.  222. 


94  DISEASES  OF  INFANTS  AND   CHILDREN. 

The  Soy  Bean.1 — This  is  very  useful  when  milk  is  badly 
borne,  and  in  certain  forms  of  intestinal  disorders  and  con- 
valescence after  diarrhea,  in  marasmus  and  malnutrition.  Soy- 
bean flour  made  by  the  Cereo  Company,  Tappau,  New  York, 
contains  120  calories  per  ounce.  A  gruel  may  be  made  by 
using  one  tablespoonful  of  soy-bean  flour,  two  tablespoonfuls 
of  barley  flour,  and  one  quart  of  water.  It  should  be  boiled 
hard  for  twenty  minutes  or  longer.  This  may  be  diluted,  if 
desired,  and  may  be  increased  in  strength  up  to  double  the 
quantity  stated.  It  may  be  used  plain  for  short  periods  and 
for  long  periods  with  the  addition  of  condensed  milk.  Cream 
may  be  added,  if  desired.  Orange  juice  should  be  given  as 
an  antiscorbutic. 

Other  Methods. — Chapin,  Coit  and  many  others  have 
devised  methods  of  milk  modification.  Gartner's  milk  is  a 
milk  modified  by  centrifugalization,  and  Backhaus'  milk  is 
prepared  in  a  somewhat  similar  way,  but  is  previously  partially 
digested  by  the  use  of  rennet,  trypsin,  and  sodium  carbonate. 

Sodium  Citrate. — Poynton,  Shaw,  and  others,  following 
the  suggestion  of  A.  E.  Wright,  recommend  the  use  of  sodium 
citrate.  The  soda  forms  a  compound  with  the  casein  and 
alters  the  curd  produced,  rendering  it  more  digestible.  The 
citric  acid  forms  calcium  citrate  by  uniting  with  the  calcium 
salts.  The  use  of  sodium  citrate  enables  one  to  give  a  milk 
containing  more  protein  than  would  otherwise  be  digested. 
It  is  useful  in  weaning  infants,  in  practice  among  the  poor 
where  milk  modification  is  imperfectly  done,  and  is  useful  in 
protein  indigestion,  and  in  some  other  cases  where  milk  is  not 
well  borne  without  the  sodium  citrate.  From  1  to  3  gr.  to 
the  ounce  may  be  used.  It  may  be  ordered  in  solution  in 
water  in  which  it  is  freely  soluble.  A  drop  or  two  of  chloro- 
form should  be  added  to  prevent  the  growth  of  organisms 
which  is  liable  to  take  place. 

Beginning  Bottle-feeding.2 — In  order  to  succeed  it  is 
necessary  that  this  method  be  begun  properly.  The  percent- 
age used  to  begin  with  should   always   be  well   within  the 

1  See  Friedenwald  and  Ruhriih,  "Diet  in  Health  and  Disease,"  Fourth 
Edition. 

2  H.  L.  K.  Shaw,  "  Citrate  of  Soda  in  Infant  Feeding,"  Archives  of 
Pediatrics,  March,  1906,  p.  161. 


INFANT  FEEDING 


95 


infant's  digestive  powers,  and  raised  as  rapidly  as  possible  to 
a  milk  suited  to  the  age  of  the  infant.  It  is  a  good  plan  to 
start  with  a  milk  given  in  the  schedule  for  a  babv  one-third 
the  age  of  the  one  to  be  fed.  Each  day,  or  even  at  longer 
intervals  if  necessary,  the  milk  may  be  made  slightly  stronger. 
If  the  milk  is  made  too  strong  at  first  or  the  percentage 
raised  too  rapidly,  indigestion,  colic,  and  offensive  stools  will 
be  the  result.  On  the  other  hand,  the 
opposite  mistake,  that  of  feeding  an  in- 
fant on  a  milk  too  weak,  should  also  be 
avoided.  When  the  mistake  is  made, 
the  infant  becomes  pale,  cries,  and  does 
not  increase  in  weight.  Severe  hunger 
may  result,  and  symptoms  of  inanition 
may  follow. 

Technic  of  Modifying-  Milk  at 
Home. — To  insure  success  a  very  care- 
ful technic  must  be  followed.  In  the  ab- 
sence of  a  nurse  specially  trained  for  the 
purpose  the  physician  should  give  careful 
written  and  verbal  instructions,  and  then 
to  see  personally  that  these  are  carried  out. 
Knowledge  on  the  part  of  the  mother  or 
nurse  should  not  be  assumed,  for,  as  a 
rule,  she  does  not  possess  it. 

The  vessels  and  instruments  used 
should  be  kept  scrupulously  clean,  and 
be  used  solely  for  the  purpose  intended. 
After  use,  or  what  is  decidedly  better, 
just  previous  to  being  used,  they  should  be 
either  boiled  or  scalded  with  boiling  water,  preferably  the  former. 

The  nursing-bottles  should  have  rounded  bottoms,  so  that 
there  are  no  corners  for  holding  dirt,  and  also  that  they  can- 
not be  stood  about  the  room.  If  only  one  or  two  bottles  are 
used,  they  should  be  scalded  after  each  feeding  and  filled 
either  with  boric  acid  or  sodium  bicarbonate  solution,  made 
by  adding  a  teaspoonful  of  either  drug  to  a  pint  of  water. 
When  the  bottle  is  to  be  used  again,  the  solution  should  be 
poured  out  and  the  bottle  rinsed  with  plain  sterile  water. 


Fir;.  25.— Hygienic  nurs- 
ing bottle  (De  Lee). 


96 


DISEASES  OF  INFANTS  AND   CHILDREN. 


The  nipples  should  be  of  the  ordinary  short  black-rubber 
variety.  White  nipples,  which  are  said  to  contain  lead,  as 
well  as  all  complicated  nipples  and  tubes,  should  be  avoided. 
These  latter  cannot  be  kept  clean,  and  are  a  source  of  infec- 
tion diarrhea.  In  some  cities  their  sale  is  prohibited  by  law. 
_After  each  feeding  the  nipple  should  be  washed,  turning  it 
insicle  out  to  do  this  thoroughly,  and  then  placed  in  a  glass 
of  boric  acid  solution  (3J-Oj).  It  is  a  good  plan  to  have 
several  nipples  on  hand  and  to  boil  them  before  using  them 
for  the  first  time,  and  then  for  five  minutes  every  day.  The 
hole  or  holes  in  the  nipple  should  be  just  large  enough  to 
allow  the  milk  to  drop  out  somewhat  rapidly.  It  should  not 
flow  out  in  a  stream.  If  the  holes  are  too  small,  they  may 
be  enlarged  or  new  ones  made  by  using  a  red-hot  darning- 
needle.  Some  nipples  are  made  without  holes,  and  these 
may  be  perforated  in  the  same  manner. 

Preparation. — It  is  best  to  pre- 
pare the  entire  quantity  for  twenty- 
four  hours  at  one  time.  If  the 
weather  is  warm,  the  milk  must  be 


Fig.  26.— Freeman's  pasteurizer. 


Fig.  27.— Arnold  sterilizer. 


pasteurized  or  sterilized  immediately.  If  neither  can  be 
done,  then,  unless  the  weather  is  cold  and  a  clean  milk  can 
be  obtained,  but  one  feeding  should  be  prepared  at  a  time. 

The  physician  should  always  write  out  the  quantities  to  be 
used  for  preparing  the  milk.  The  milk-  or  cane-sugar  is  dis- 
solved in  hot  water.     Care  should  be  taken  to  use  a  sugar 


INFANT  FEEDING.  97 

that  gives  a  clear  .solution  without  filtering.  If  the  solution 
is  not  clear,  it  should  be  filtered  through  a  wad  of  cotton 
placed  in  the  bottom  of  a  funnel  or  through  a  piece  of  drug- 
gist's filter-paper.  This  solution,  together  with  the  lime- 
water  or  sodium  bicarbonate,  should  be  poured  into  a  pitcher. 
Into  this  the  milk,  or  milk  and  cream,  should  be  poured, 
and  the  remainder  of  the  water  added.  The  water  should 
always  be  boiled.  The  mixture  should  then  be  stirred  and 
poured  into  the  nursing-bottles.  The  bottles  should  then  be 
stoppered  with  moderately  tight  plugs  of  non-absorbent  cot- 
ton, to  keep  out  bacteria.  The  bottles  are  then  pasteurized 
or  sterilized  and  placed  in  a  refrigerator. 

At  the  feeding  hour  the  bottle  is  taken  out  of  the  refriger- 
ator, placed  in  a  pitcher  or  tall  vessel  of  hot  water  to  warm 
it,  the  cotton  plug  removed,  and  a  nipple  substituted.  The 
milk  should  be  heated  until  it  is  lukewarm — about  98°-99°  F. 
The  nipple  should  never  be  placed  in  the  mouth  to  test  the 
heat,  but  the  milk  may  be  allowed  to  drop  on  the  wrist,  where 
it  should  feel  warm,  but  not  hot. 

FEEDING  DURING  THE  SECOND  YEAR. 

During  the  second  year  of  life  as  much  care  is  required 
in  feeding  as  during  the  first.  The  fear  of  the  second  sum- 
mer would  largely  be  overcome  if  the  child  were  not  allowed 
to  eat  food  unsuited  to  its  digestion.  Most  of  the  illness  and 
many  of  the  deaths  of  childhood  are  traceable  to  improper  diet. 

During  the  second  year  milk  should  form  the  basis  of  the 
diet.  In  cities  or  where  the  milk-supply  is  not  above  sus- 
picion, it  is  best  to  pasteurize  the  milk  until  the  second  sum- 
mer has  been  passed,  or  even  longer  if  circumstances  war- 
rant. As  a  rule,  the  milk  requires  but  little  modification, 
and  after  the  eighteenth  month,  and  often  before,  may  gen- 
erally be  taken  unmodified.  As  the  child  is  now  able  to 
digest  starchy  food,  milk-sugar  may  be  omitted.  In  cases 
where  the  milk  is  not  thoroughly  digested,  as  is  evidenced 
by  curds  in  the  stools,  lime-water  may  be  used,  and  may  be 
added  in  quantities  of  from  5  to  10  per  cent.,  or  even  more 
if  necessary.     During  illness  and  often  under  other  circum- 


98  DISEASES  OF  INFANTS  AND  CHILDREN. 

stances  the  alkaline  carbonated  waters  will  be  found  useful 
for  diluting  the  milk.  If  the  milk  is  poor,  another  plan  is 
to  use  the  upper  two-thirds  of  the  milk. 

Starchy  food  may  be  given  in  the  form  of  gruel,  either 
alone  or,  what  is  better,  mixed  with  milk.  Barley-gruel  or, 
if  there  is  a  tendency  to  constipation,  oatmeal-gruel  is  added, 
one-fifth  or  one-fourth  part  of  gruel  being  added  to  each 
feeding.  The  gruel  should  be  freshly  prepared  and  mixed 
immediately  with  the  milk.  A  pinch  of  salt  and  a  very 
small  quantity  of  cane-sugar  may  be  added  to  render  it  more 
palatable. 

During  the  second  year  five  meals  at  about  four-hour 
intervals  should  be  given.  The  bottle  should  be  dispensed 
with,  and  the  food  be  taken  from  a  cup  or  spoon.  If  the 
bottle  is  not  taken  from  the  child  early,  it  may  be  difficult  to 
break  it  of  the  bottle  habit.  The  following  diet-lists  for 
different  ages  will  be  found  useful : 

Twelfth  to  Fifteenth  Month. — Milk,  barley,  oatmeal,  wheat- 
flour,  farina,  or  arrow-root  gruel ;  barley  or  oatmeal  jelly  ; 
lightly  boiled  yolk  of  egg,  given  with  stale  bread-crumbs. 

Beef,  mutton,  and  chicken  broth,  chicken  jelly,  beef-juice. 

Orange-juice  or  the  juice  of  other  ripe  fruit,  as  of  peaches. 

First  Meal. — On  waking,  the  child  should  receive  a  cup 
of  warm  milk,  modified  as  previously  suggested.  If  the 
child  is  accustomed  to  waking  very  early,  more  milk  may  be 
given  at  about  7  A.  M.  ;  otherwise  this  last  may  be  regarded 
as  the  first  meal. 

Second  Meal  (10.30  A.  m.). — Eight  ounces  of  warm  milk 
and  barley-gruel. 

Third  Meal  (2  p.  m.). — One  of  the  following  : 

(a)  Eight  ounces  (a  cupful)  of  beef     broth. 

(b)  "  "  "  veal         " 

(c)  "  "  "  mutton    " 

(d)  «  "  "  _  chicken  " 

(e)  Yolk  of  a  lightly  boiled  egg  with  stale- 

bread  crumbs. 

Fourth  Meal  (5  p.  m.). — Eight  ounces  of  milk  and  barley- 
gruel. 


INFANT  FEEDING.  99 

Fifth  Meal  (10  p.  m.,  if  required). — Eight  ounces  of  milk. 

Orange-juice,  one  or  two  tablespoonfuls  at  a  time  may  be 
given  one  hour  before  the  10.30  A.  m.  feeding.  If  there  is 
a  tendency  to  loose  bowels,  this  should  be  omitted. 

If  the  child's  appetite  is  very  good,  a  small  piece  of  zwie- 
back may  be  given  with  either  the  second  or  the  fourth  meal. 
This  should  not  be  soaked  in  the  milk,  but  the  child  should 
be  allowed  to  nibble  at  it  dry. 

Fifteen  to  Eighteen  Months. — Same  as  above,  together  with 
zwieback,  stale  bread  (oven  dried),  whole  eggs  very  soft 
boiled ;  strained  oatmeal,  barley  or  wheat  porridge ;  bread 
and  milk,  thin  biscuit  (crackers),  junket,  scraped  raw  beef 
or  mutton  in  very  small  quantities. 

Eighteen  Months  to  Two  and  One-half  Years. — Milk  is  to 
be  regarded  as  the  chief  article  of  diet.  Many  children  have 
no  desire  for  other  foods  until  after  the  second  or  third  year. 
These  children  will  generally  be  found  to  thrive  on  milk 
alone  or  with  slight  additions  to  the  diet.  As  the  child's 
digestive  power  increases,  the  following  articles  may,  how- 
ever, be  added  one  at  a  time  : 

Fruits. — Juice  of  ripe  fresh  fruit,  that  of  oranges  and 
peaches  being  best.  Ripe  fresh  grapes  skinned  and  seeded. 
Baked  apple — pulp  only,  the  skin  and  seeds  to  be  carefully 
removed.  Stewed  prunes,  the  skins  to  be  removed  by  passing 
through  a  sieve. 

Meats. — Scraped  raw  beef  or  mutton  ;  rare  roast-beef  or 
mutton  pounded  to  a  pulp.  Chicken  or  turkey,  the  lean  white 
meat  minced  to  a  pulp. 

Vegetables. — Mashed  baked  potato  with  cream  or  covered 
with  gravy  from  roast  meats.  If  the  latter  is  very  fat,  the 
fat  should  be  removed  by  skimming  or  by  means  of  a  piece 
of  blotting-paper.  Very  well-cooked  spinach,  celery,  and 
cauliflower  tops. 

Cereals. — Well-boiled  rice  and  other  well-cooked  cereals 
already  mentioned. 

Desserts. — Boiled  custard,  milk  and  rice  puddings,  junket. 

Four  meals  will  generally  suffice  after  the  eighteenth  month. 

From  two  and  one-half  years  up  to  the  sixth  year  the  diet 


100  DISEASES  OF  INFANTS  AND   CHILDREN. 

of  the  child  may  gradually  be  increased.  Milk  .should  still, 
however,  be  taken  in  large  quantities — about  a  quart  daily — 
as  well  as  some  form  of  cereal  for  breakfast,  with  or  without 
an  egg,  or  fresh  fruit  if  there  is  a  tendency  to  constipation. 
Meat  prepared  as  above  should  be  given  once  a  day,  and  pref- 
erably at  the  midday  meal,  together  with  potato  and  some 
green  vegetable,  as  spinach,  asparagus,  or  cauliflower  tops. 
The  evening  meal  should  be  light,  and  consist  of  bread  and 
milk. 

It  is  well  to  prepare  two  lists,  which  may  be  given  to  the 
nurse  or  mother  as  a  guide.  One  list  should  contain  the  food 
allowed,  and  the  other  list  those  forbidden.  It  is  not  well  to 
depend  on  verbal  instructions  as  they  are  easily  forgotten  or 
misconstrued. 

THE  DIET  FROM  TWO  AND  ONE-HALF  TO  SIX  YEARS, 

Milk  may  be  allowed  with  every  meal  (may  be  omitted 
from  dinner  if  desired).  The  average  child  should  take  a 
quart  a  day,  plain  or,  when  plain  milk  is  not  thoroughly 
digested,  modified  as  for  twelve  to  fifteen  months. 

Cream. — Two  to  eight  ounces  a  day  mixed  with  the  milk, 
taken  as  a  beverage,  with  cereals,  etc. 

Bread  and  biscuit  may  be  allowed  with  every  meal,  stale 
bread,  dried  bread,  also  the  so-called  "  pulled  bread,"  zwieback, 
and  the  various  forms  of  biscuits  or  crackers. 

Cereals. — Almost  any  kind  of  cereal  for  breakfast ;  oat- 
meal and  wheaten  grits  are  the  best.  Rice  and  hominy  for 
dinner.     Barley  is  useful  in  soups. 

Vegetables  may  be  allowed  for  dinner — potatoes  in  some 
form  or  a  cereal  with  one  green  vegetable ;  spinach,  cauli- 
flower tops,  and  the  like  are  the  best. 

Eggs  are  very  good,  but  children  are  liable  to  tire  of  them 
easily.  They  should  be  given  for  breakfast,  as  a  rule,  but 
never  day  after  day. 

Meats. — Allowed  once  a  day  for  dinner  and  in  older  chil- 
dren for  breakfast  occasionally.  Boiled  or  broiled  fish  may  be 
given  for  breakfast  or  dinner. 


INF  A  NT  FEEDING.  ]  01 

Broths  and  soups  of  simple  composition  may  be  eaten. 
Meat  1  >roths  with  cream  and  cereals  are  especially  nutritious. 

Desserts. — Once  a  day,  with  dinner.  Plain  custard,  milk 
and  rice  pudding,  bread  and  custard  pudding,  and  junket  are 
the  best;  ice-cream  once  a  week.  Fruit  should  be  given 
once  daily,  and  only  ripe  fresh  fruit,  in  season,  should  be 
used.  The  best  are  oranges,  baked  apples,  and  stewed  prunes. 
Ripe  peaches,  pears,  grapes  without  skins  or  seeds,  may  also 
be  given.  Fresh  juice  of  berries  in  small  quantity,  straw- 
berries in  perfect  condition  sparingly.  Ripe  cantaloupe  and 
watermelon  in  moderate  quantities  may  also  be  allowed. 
Great  care  should  be  used  in  choosing  and  giving  fruit  to 
children.  It  is  a  very  important  article  of  diet,  but  if  stale, 
spoiled,  or  unripe,  is  capable  of  doing  much  harm.  Too  much 
should  not  be  given  in  hot  weather.  Lemonade  is  useful 
during  very  hot  weather. 

Articles  Forbidden  (after  Holt). — The  following  arti- 
cles should  not  be  allowed  children  under  four  years  of  age, 
and  with  few  exceptions  they  may  be  withheld  with  advantage 
up  to  the  seventh  year. 

Meats. — Ham,  sausage,  pork  in  all  forms,  salted  fish, 
corned  beef,  dried  beef,  goose,  game,  kidney,  liver,  bacon, 
meat-stews,  and  dressing  from  roasted  meats. 

Vegetables. — Fried  vegetables  of  all  varieties,  cabbage, 
potatoes  (except  when  boiled  or  roasted),  raw  or  fried  onions, 
raw  celery,  radishes,  lettuce,  cucumbers,  tomatoes  (raw  or 
cooked),  beets,  egg-plant,  and  green  corn. 

Bread  and  Cake. — All  hot  bread  and  rolls ;  buckwheat 
and  all  other  griddle-cakes  ;  all  sweet  cakes,  particularly  those 
containing  dried  fruits  and  those  heavily  frosted. 

Desserts. — All  nuts,  candies,  pies,  tarts,  and  pastry  of  every 
description  ;  also  salads,  jellies,  syrups,  and  preserves. 

Drinks. — Tea,  coffee,  wine,  beer,  and  cider. 

Fruits. — All  dried,  canned,  and  preserved  fruits  ;  bananas  ; 
all  fruits  out  of  season  and  stale  fruits,  particularly  in  sum- 
mer. 

The  meals  should  be  given  at  fixed  hours,  which  practice 
should  be  strictly  adhered  to.     Feeding  between  meals,  even 


i02  DISEASES  OF  INFANTS  AND  CHILDREN. 

when  consisting  of  the  most  trifling  things,  should  be  avoided. 
If  the  child  cannot  go  from  one  meal  to  another  without 
discomfort,  the  intervals  should  be  shortened.  In  certain 
cases  it  may  be  advisable  to  give  a  small  cup  of  milk  or  broth 
and  a  cracker  between  the  meals,  at  stated  intervals,  as  in 
feeding  younger  children. 

Caiwiies,  cakes,  and  the  like  should  be  kept  from  young 
children.  In  well-regulated  homes,  if  he  once  learns  that  he 
cannot  have  them,  the  child  will  soon  cease  to  demand  sweets. 
The  frequent  indulgence  in  sweets  of  various  kinds  creates 
a  desire  for  them  to  the  exclusion  of  other  food.  This  cra- 
ving is  analogous  to  that  for  alcohol  in  adults.  Overindul- 
gence in  sweets  causes  indigestion,  headache,  and  the  like, 
ailments  that  may  easily  be  prevented. 

The  child  should  be  taught  to  eat  slowly  and  to  chew  the 
food  well.  To  this  end,  some  older  individual  should  always 
be  present  at  meal-time  to  see  that  sufficient  time  be  taken 
for  the  meal,  and  that  the  food  be  finely  divided,  as  young 
children  do  not,  as  a  rule,  chew  very  well.  The  quantity 
given  to  a  healthy  child  should  depend  on  his  appetite.  In 
sick  children  this  is  not  a  reliable  guide,  and,  where  possible, 
fixed  amounts  may  be  given.  The  child  should  not  be  forced 
to  eat,  nor  should  he  be  given  special  articles  to  tempt  the 
appetite.  If  the  food  offered  is  not  taken,  it  is  well  to  wait 
until  the  next  meal,  when  it  will  generally  be  found  that  the 
appetite  has  returned.  Loss  of  appetite  is  often  merely  an 
indication  that  the  digestive  organs  require  a  slight  rest. 

During  the  heated  portions  of  the  year  the  child  will  re- 
quire less  solid  and  more  liquid  food.  The  same  is  true  during 
sickness.  Many  of  the  gastro-intestinal  disturbances  attributed 
to  teething  are  the  result  of  improper  feeding. 

DIET   OF  SCHOOL   CHILDREN. 

The  period  usually  spoken  of  as  "  school  days  "  is  an  ex- 
tremely active  one  physically.  The  vast  number  of  meta- 
bolic changes  going  on  and  the  growth  of  the  body  demand  a 
plentiful  and  a  suitable  diet.  Both  in  and  out  of  school  and 
in  seminaries  careful  attention  should  be  given  to  food,  fresh 


INFANT  FEEDING.  103 

air,  and  exercise.  In  other  words,  the  physical  develop- 
ment should  receive  as  much  attention  as  the  mental  growth. 
In  boarding-schools  especially  the  diet  should  be  the  subject 
of  careful  study,  the  aim  being  to  avoid  monotony  and  to 
provide  a  sufficient  and  satisfying  diet.  In  many  schools 
the  dietary  is  left  to  the  discretion  of  the  cook.  In  consider- 
ing school  dietaries  several  points  are  worthy  of  consideration. 

Milk,  being  easily  digested  in  most  cases,  is  of  great  value, 
especially  for  children  whose  nutrition  is  below  normal.  It 
should  be  furnished  as  a  beverage  daily  for  breakfast  and 
supper,  and  is  advisable  even  with  dinner.  It  may  also  be 
used  in  the  preparation  of  puddings  and  soups.  Cream  is 
very  valuable,  and  whenever  possible  should  be  supplied  in 
sufficient  quantities.  A  cup  of  warm  milk  with  bread  or 
crackers  is  helpful  during  the  middle  of  the  morning,  and  as 
a  substitute  for  tea  in  the  afternoou.  Delicate  children  and 
others  may  with  advantage  take  a  glass  of  warm  milk  a 
short  time  before  going  to  bed.  If  the  rising  hour  is  some 
time  before  that  set  for  breakfast  a  cup  of  milk  or  of  bread 
and  milk  should  be  given  on  rising. 

I$ggS  may  be  used  alone  or  in  the  preparation  of  various 
dishes.  They  may  be  used  in  almost  any  way,  except  fried. 
Fried  eggs  are  liable  to  be  very  indigestible.  They  are  often 
prepared  in  this  way  in  order  to  disguise  the  stale  taste  of  an 
egg  that  has  been  in  storage  for  some  time. 

Meat  is  a  very  important  part  of  the  diet,  as  it  contains  a 
larger  quantity  of  protein,  from  which  the  tissues  are  built 
up,  and  in  a  more  available  form,  than  in  any  other  form  of 
food.  Milk  and  eggs  are  also  valuable  sources  of  protein. 
Meat  should  be  provided,  therefore,  in  sufficient  quantities, 
half  a  pound  a  day  being,  perhaps,  a  good  average  allowance 
for  a  growing  boy,  the  larger  and  more  robust  taking  some- 
what more.  Steaks,  chops,  and  roasts  of  beef,  mutton,  lamb, 
fowl,  and  bacon  are  the  most  suitable  meats,  although  pork, 
together  with  meat  stews,  meat  puddings,  sausages,  and 
hashes  may  be  allowed  in  small  quantities.  These  last,  while 
generally  relished,  are  not  so  digestible  nor  such  good  sources 
of  nutriment  as  those  first  named.     With  care  and  proper 


104  DISEASES  OF  INFANTS  AND   CHILDREN 

preparation  many  of  their  ill  effects  can  be  obviated.  More 
meat  is  required  in  winter  than  in  summer,  and  more  in  cold 
climates  than  in  warm..  Yeo  states  that  too  much  meat  may 
give  rise  to  eczema. 

Meat  may  be  given  twice  a  clay,  and  eggs  or  fresh  fish 
may  be  substituted  for  it  about  three  times  a  week.  When 
these  do  not  satisfy  the  appetite  meat  may  be  added.  For 
this  purpose  cold  sliced  meat  is  useful. 

Bread  and  butter  should  be  given  with  each  meal.  Bread 
made  from  the  whole  wheat-flour  may  be  used  in  the  largest 
quantity,  but  it  is  well  to  supply  various  kinds  of  bread  to 
avoid  monotony.  "Brown  bread"  given  continuously  be- 
comes very  tiresome.  Rye  bread  may  be  given  occasionally, 
and  bread  made  from  mixtures  of  wheat  and  rye  is  very 
palatable.  Rusk,  biscuit,  and  crackers  may  also  be  supplied. 
Corn-bread,  when  properly  made,  may  be  given  once  a  week 
or  oftener,  and  griddle  cakes  of  buckwheat,  corn,  or  wheat 
flour  two  or  three  times  a  week.  These  last  may  be  served 
with  syrup  or  fruit-juices. 

Cereal  porridges  of  all  kinds  may  be  given  for  break- 
fast, oatmeal  being  probably  the  most  desirable. 

Vegetables  of  almost  all  varieties  may  be  used.  For 
dinner  two  varieties  should  be  given — one  green  vegetable 
and  potatoes.  Salads  made  of  the  green  vegetables,  with  the 
very  simplest  dressings,  are  useful  additions  to  the  diet. 

Fruit  should  invariably  be  given  once  a  day. 

Sugar  should  be  provided  for  in  the  dietary.  Candies 
and  many  of  the  sweets  given  to  children  are  harmful  and 
cause  indigestion  and  dyspepsia.  If  proper  sweets  were  pro- 
vided there  would  be  slighter  tendency  to  indulge  in  the  less 
desirable  forms  whenever  opportunity  afforded.  With  the 
meals,  and  when  the  appetite  demands  satisfying  between 
meals,  they  may  be  given  with  or  without  a  glass  of  milk. 
Regularity  should,  however,  be  observed,  and  they  should 
not  be  ffiven  immediatelv  before  or  after  a  meal.  Fruit 
syrups,  sugar  syrups,  honey,  preserved  fruits,  and  jam  may 
be  eaten  with  bread.  Caramels,  chocolates,  maple  sugar,  and 
plain  sugar  taffies  are  the  best  of  the  other  forms  of  sweets. 


INFANT  FEEDING.  105 

Simple  desserts,  such  as  custards,  milk  puddings  with 
rice,  tapioca,  and  the  like,  bread  puddings,  plain  cakes,  and 
properly  prepared  pastry  may  be  \\>v<\. 

The  beverages  should  be  water  and  milk.  Weak  cocoa 
or  chocolate  may  be  given  after  the  seventh  year.  Tea  and 
coffee  should  not  be  given  before  the  thirteenth  year,  and 
may  be  withheld  advantageously  still  longer.  Alcohol  is 
not  to  be  used  except  by  a  physician's  direction. 

Especial  care  should  be  taken  to  avoid  a  monotonous  diet, 
for  there  are  many  instances  where  the  constant  repetition  of 
a  certain  form  of  food  has  created  a  dislike  for  it  that  has 
persisted  throughout  life  or  been  overcome  only  with  diffi- 
culty. 

A  second  point  to  be  remembered  is  that  the  food  should 
be  well  prepared  and  attractively  served.  This  has  more  to 
do  with  influencing  the  appetite  of  delicate,  nervous  children 
than  is  generally  supposed,  and  cannot  be  insisted  upon  too 
strongly. 

Overeating  should  be  avoided,  and  to  this  end  an  older 
person  should  always  be  present  when  practicable  ;  in  school 
this  should  be  insisted  upon.  On  the  other  hand,  a  child 
should  not,  through  caprice  or  habit,  be  allowed  to  eat  too 
little.  By  exercising  a  little  tact  most  of  the  dislikes  which 
are  not  deeply  rooted,  but  which  may  become  so  if  persisted 
in,  may  generally  be  overcome.  These  dislikes  are  often  the 
result  of  imitation. 

Sufficient  time  should  be  allowed  not  only  for  the  meal, 
but  for  the  performance  of  whatever  small  duties  may  be 
required  of  the  child.  A  time  should  be  set  for  one  or  two 
regular  daily  visits  to  the  water-closet.  Hurrying  to  school 
should  be  avoided.  Reading  and  studying  immediately 
before  and  after  meals  should  be  prohibited,  as  should  bath- 
ing or  any  very  active  exercise.  Some  light  form  of  recrea- 
tion may,  however,  be  indulged  in.  The  hours  for  meals 
should  be  so  arranged  that  the  child  may  have  freshly  pre- 
pared meals,  and  not  cold  luncheons  or  warmed-over  dinners. 
Lastly,  nibbling  and  eating  between  meals,  except  under  the 
conditions  previously  described,  should  be  strictly  prohibited. 


106  DISEASES  OF  INFANTS  AND   CHILDREN. 

In  spite  of  stringent  rules,  however,  many  infringements  will 
occur. 

It  is  by  neglect  of  the  diet,  fresh  air,  and  exercise  that 
many  cases  of  tuberculosis  gain  headway  ;  anemia  may  result 
from  such-  neglect,  and  a  delicate,  nervous  child  be  the  out- 
come of  one  that  should  by  right  be  healthy. 

OTHER  FACTORS  IN  INFANT  FEEDING* 

Feeding  in  Infant  Asylums. — The  feeding  of  infants 
in  overcrowded  infant  asylums,  with  their  lack  of  fresh  air 
and  paucity  of  attendants,  is  a  matter  of  great  difficulty. 
Any  attempt  at  scientific  feeding  under  such  circumstances 
will  ultimately  lead  to  failure,  the  method  in  these  cases 
being  held  to  blame.  The  primary  cause  of  malnutrition 
and  marasmus  in  institutions  is  the  lack  of  fresh  air  and  in- 
dividual care,  and  until  these  are  obtainable  it  is  useless  to 
attempt  to  accomplish  anything  by  special  feeding  methods. 
In  smaller  institutions  the  use  of  the  Materna  graduate  will 
be  found  satisfactory. 

In  the  larger  asylums  it  is  well  to  have  two  or  three  gen- 
eral working  formulas,  such  as  fat  3  per  cent.,  sugar  6  per 
cent.,  protein  1  per  cent.  ;  and  fat  4  per  cent.,  sugar  7  per 
cent.,  protein  2  per  cent.  These  may  be  varied  by  adding 
more  or  less  water  to  them  to  adapt  them  more  closely  to 
special  needs.  The  younger  infants  rnjiy,  when  possible,  re- 
ceive special  mixtures.  For  substitute  feeding,  condensed 
milk,  barley-  and  egg-water  will  be  found  most  useful. 

The  allowance  of  a  few  cents  a  day  generally  made  for  an 
infant's  entire  care  is  quite  inadequate  to  accomplish  any 
good. 

The  Infant's  Stools. — An  examination  of  the  stools 
should  be  regarded  as  part  of  the  routine  examination.  The 
number  of  stools  in  the  twenty-fours  is  not  as  important  as 
their  character.  As  long  as  the  character  of  the  stool  is 
normal  the  child  is  not  said  to  have  diarrhea  even  if  it  has  a 
number  of  stools  daily. 

The  normal  stool  is  smooth,  about  the  consistence  of  butter 


INFANT  FEEDING.  107 

and  contains  no  curds  or  solid  masses.  Mucus  is  not  seen  in 
the  perfectly  normal  stool,  but  can  usually  be  demonstrated 
microscopically. 

The  reaction  of  infants'  stools  is  usually  acid  or  neutral, 
although  sometimes  it  is  alkaline.  Either  acid  or  alkaline 
stools  may  be  altered  in  color.  A  return"  to  a  normal  color 
is  usually  brought  about  in  these  cases  by  the  administration 
of  an  alkali  when  the  stools  are  acid,  and  vice  versa.  Alka- 
line stools,  green  in  color,  may  be  produced  by  giving  alkalies 
in  large  doses  for  several  days.  The  color  of  the  stools  fur- 
nishes considerable  information  as  to  the  condition  of  the 
infant.  Normally  the  color  is  a  light  butter-yellow,  but  the 
stools  may  vary  somewhat  in  this  respect  and  be  lighter  or 
darker.  In  young  breast-fed  infants  the  stools  may  be  a 
dark  yellow,  like  the  yolk  of  an  egg.  In  artificially  fed 
babies  the  stools  are  frequently  very  light  in  color,  or  even 
decidedly  whitish.  Rhubarb  imparts  a  yellow  color  to  the 
stool. 

White  stools  are  seen  sometimes  in  artificially  fed  children 
that  seem  to  be  otherwise  in  normal  condition.  As  a  rule, 
however,  white  stools  are  either  the  result  of  the  ingestion  of 
excessive  quantities  of  fat  or  indicate  an  absence  of  bile.  In 
the  former  cases  the  stools  are  large,  whitish,  and  have  the 
characteristic  odor  of  fatty  acids,  which  resembles  that  of 
rancid  butter.  The  stool  may  be  dried  and  burnt  with  the 
same  odor  and  the  fat  may  be  dissolved  by  ether.  AVhen  bile 
is  absent,  the  stools  are  white  and  have  a  very  foul,  almost 
cadaveric,  odor. 

Red  stools  may  owe  their  color  to  the  presence  of  fresh 
blood  from  the  rectum  or  the  lower  part  of  the  intestinal 
tract.  When  it  comes  from  the  upper  parts,  the  blood  is 
always  black.  The  streaks  of  fresh  blood  frequently  seen 
where  hard  stools  are  passed  come  from  slight  excoriations  of 
the  anus. 

Black  stools  are  caused  by  the  presence  of  blood.  In  this 
case  the  stools  are  black  and  tarry.  The  blood  may  come 
from  the  intestines  or  stomach,  or  from  blood  swallowed, 
especially  that  from  hemorrhage  from  the  posterior  nares. 


108  DISEASES  OF  INFANTS  AND   CHILDREN. 

Black  or  blackish-brown  stools  may  also  be  caused  by  the 
administration  of  bismuth,  iron,  or  tannic  acid.  Brown  stools 
are  frequently  seen  as  the  result  of  bacterial  and  chemic 
changes  in  the  intestine  in  the  course  of  intestinal  indigestion 
and  intestinal  infection.  Raw  beef-juice  may  give  rise  to 
foul-smelling  brownish  or  grayish-colored  stools. 

Green  stools  are  due  to  a  large  number  of  causes.  This 
may  result  from  intestinal  indigestion  and  infection  due  to 
improper  food,  usually  either  an  excess  of  sugar  or  of  fat,  or 
to  the  presence  of  bacteria.  Calomel  causes  green  stools,  and 
alkalies,  if  continued  and  not  neutralized  in  the  stomach,  may 
produce  the  same  effect. 

Symptoms  of  Dietetic  Errors. — Too  much  stress  can- 
not be  laid  upon  the  importance  of  investigating  the  source 
of  disturbances  due  to  dietetic  errors. 

Too  Low  Protein. — The  stools  are  small  and  constipated,  if 
the  other  food  elements  are  low,  as  they  usually  are.  The 
child  does  not  gain  weight  so  rapidly  as  a  normal  child,  or  it 
may  remain  stationary  or  even  lose  weight.  It  is  anemic, 
and  if  the  low  protein  is  continued  the  child  becomes 
marantic. 

Too  High  Protein. — The  child  is  liable  to  have  colic,  vom- 
iting at  any  time,  but  usually  half  an  hour  or  more  after 
feeding.  The  stools  contain  undigested  curds  and  mucus, 
and  may  be  yellowish  green  or  otherwise  discolored. 

Too  Low  Sugar. — The  gain  in  weight  is  liable  to  be  slow, 
and  the  child  may  be  constipated.  These  infants  are  usually 
thin. 

Too  High  Sugar. — Vomiting  an  hour  or  two  after  meals, 
the  vomited  matter  usually  being  sour.  Acid  eructations  are 
common.  Colic  is  frequent.  The  stools  are  generally  grass 
green  and  very  irritating,  the  buttocks  often  being  exco- 
riated. 

Too  Low  Fat. — The  child  gains  weight  slowly,  and  is 
usually  constipated  unless  an  excess  of  sugar  is  given,  as 
in  condensed-milk  feeding. 

Too  High  Fat. — The  child  vomits  an  hour  or  two  after 
feeding.     Colic  is   common.     The  stools   may  be  thin  and 


INFANT  FEEDING.  109 

green  or  greenish  yellow,  and  contain  small  masses  of  undi- 
gested fat  and  considerable  mucus.  These  small  lumps  are 
often  mistaken  for  curds.  They  are  more  or  less  translucent, 
and  when  burnt  give  off  the  odor  of  fatty  acids  ;  they  may 
be  dissolved  in  ether.  Curds  are  not,  however,  dissolved  in 
ether.  Too  much  fat  may  also  cause  large,  white,  rather  dry 
stools  having  the  odor  of  rancid  butter. 

It  must  be  remembered  that  the  condition  of  the  stools 
may  be  due  to  one  or  more  of  the  food  elements,  and  expe- 
rience in  these  cases  is  the  best  teacher. 

THE   FEEDING  OF  SICK  INFANTS. 

The  Feeding  of  Difficult  Cases — At  the  outset  it  must 
be  remembered  that  the  fault  may  not  be  due  to  the  food  itself, 
but  to  its  preparation  or  to  the  mode  or  time  of  administra- 
tion, and  to  improper  surroundings  and  care.  To  succeed  in 
these  difficult  cases  it  is  necessary  to  look  diligently  into  the 
minutest  details  of  the  infant's  life. 

I,OSS  of  Weight. — Loss  of  weight  in  an  infant  should 
always  be  considered  a  very  serious  symptom.  During  an 
acute  illness,  such  as  pneumonia  or  diarrhea,  this  is  to  be 
expected.  In  chronic  conditions  the  weight  may  fluctuate, 
going  up  and  down,  or  remaining  more  or  less  stationary.  If, 
however,  in  a  period  of  a  month  or  two  there  is  no  general 
tendency  to  gain,  in  spite  of  the  fluctuation,  this  indication 
is  a  serious  matter.  Where  an  infant  is  losing  weight  with- 
out any  special  cause,  this  may  be  attributed  to  insufficient  or 
improper  food. 

In  all  cases  a  careful  study  of  the  food  is  essential.  Accu- 
rate charts  of  the  quantity  of  food  taken,  the  time,  whether 
the  child  vomits  and  at  what  time,  and  the  number  and 
character  of  the  stools,  etc.,  are  of  great  help.  If  the  food 
is  increased  or  decreased,  as  the  case  may  be,  to  an  average 
strength  for  a  child  of  the  size  and  weight  of  the  one  under 
consideration,  and  there  is  then  no  change  in  the  child's  con- 
dition, the  food  should  be  peptonized,  either  partially  or  com- 
pletely, or  mixed  with  albuminized  or  malted  food  or  with 


110  DISEASES  OF  INFANTS  AND   CHILDREN. 

barley  water.  The  addition  to  the  dietary  of  albumin  water 
or  of  small  quantities  of  one  of  the  predigested  beef  prepara- 
tions (Panopepton,  5  to  30  drops ;  Liquid  Beef  Peptonoids, 
5  drops  to  1  dram ;  or  one  of  the  other  beef  preparations  in 
similar  doses  mixed  with  water)  is  indicated.  Minute  doses 
of  nux  vomica,  or  strychnin,  with  or  without  an  alkali,  as  bi- 
carbonate of  soda,  or  creasote  (Liquid  Beef  Peptonoids  with 
creasote,  5  to  20  drops,  of  the  Arlington  Chemical  Company, 
is  an  excellent  form  in  which  to  give  creasote)  are  often 
of  value,  especially  where  tuberculosis  is  suspected.  Loss  of 
weight  may  be  caused  by  persistent  vomiting  (see  Vomiting). 

The  physiologic  loss  that  occurs  during  the  first  forty-eight 
hours  of  life  should  not  be  forgotten. 

Stationary  Weight. — This  frequently  follows  where 
an  infant  is  weaned  or  when  one  is  fed  artificially  from  the 
outset.  Even  if  the  child  is  receiving  a  correct  percentage  of 
food  it  may  not  gain  for  several  weeks.  So  long  as  the  infant 
is  well  and  the  percentage  and  quantity  given  correspond  to 
those  directed  for  an  infant  of  the  same  age  and  Aveight  no 
alarm  need  be  felt,  even  if  a  month  should  elapse  without 
showing  an  increase  in  weight.  However,  once  the  regular 
gain  in  weight  is  established  it  should  not  remain  stationary, 
but  should  increase  gradually  from  week  to  week.  The  aver- 
age weekly  gain  during  the  first  year  of  life  is  between  four 
and  eight  ounces. 

Colic. — This  is  more  liable  to  occur  in  breast-fed  than  in: 
bottle-fed  babies  on  the  percentages  usually  recommended.  It 
is  especially  likely  to  come  on  during  the  first  three  mouths. 
In  breast-fed  infants  it  is  often  a  difficult  matter  to  overcome. 
If  on  examination  the  proteins  are  found  to  be  too  high,  an 
effort  should  be  made  to  reduce  them,  and  the  intervals  of 
nursing  may  be  lengthened.  In  bottle-fed  infants  colic  is 
usually  due  to  the  fact  that  the  percentage  of  protein  is  too 
high.  The  condition  may  also  be  caused  by  the  food  being 
given  too  cold,  as  well  as  by  a  host  of  causes  that  bear  no 
relation  to  the  food. 

Vomiting. — Immediately  After  Feeding. — (a)  From  the 
food  being  given  in  too  large  quantities.     Reduce  quantity. 


INFANT  FEEDING.  Ill 

(6)  From  food  being  too  dilute,  and  so  necessitating  the 
taking  of  too  large  quantities.  Reduce  the  quantity  and 
increase  the  strength. 

(c.)  From  taking  food  too  rapidly.  Give  it  more  slowly  — 
in  breast-fed  children,  by  regulating  the  flow  by  grasping  the 
nipple  between  the  fingers;  in  bottle-fed  babies  by  using  a 
nipple  with  a  smaller  hole. 

At  Any  Time. — Due  to  the  abdominal  binder  being  too 
tight,  or  to  shaking  or  holding  the  infant  with  the  head  over 
the  nurse's  shoulder,  patting  on  the  back,  etc.  From  too 
high  proteins — this  is  more  liable  to  be  accompanied  by  other 
symptoms,  as  colic,  curds  in  stools,  etc. 

One  or  Two  Hours  After  Feeding. — The  vomited  material 
is  usually  sour  and  curdled,  or  it  may  be  watery  and  contain 
mucus.  This  is  due  to  the  percentage  of  fat  or  sugar  being 
too  high.  The  fat,  or  both  fat  and  sugar,  should  be  decreased, 
and  the  food  be  given  slowly  and  at  longer  intervals. 

Vomiting  also  occurs  in  many  diseased  conditions.  It  is 
a  frequent  accompaniment  of  gastric  and  intestinal  disorders, 
infection,  and  all  acute  diseases  ;  it  occurs  in  nervous  dis- 
eases, such  as  meningitis,  and  in  brain  tumor,  in  peritonitis, 
and  in  intestinal  obstruction,  with  coughing  spells,  as  a  habit, 
or  reflexly  from  intestinal  or  pharyngeal  irritation,  or  in 
toxic  conditions,  such  as  uremia.  The  treatment  depends  on 
removal  of  the  cause  where  possible.  When  it  occurs  in. 
ordinary  acute  diseases,  however,  much  can  be  done  in  a 
general  way  to  overcome  vomiting.  The  food  should  be 
given  in  sufficiently  small  quantities  at  two-hour  intervals,  or 
in  some  cases  a  teaspoonful  of  food  may  be  given  every  hour, 
or  even  every  half-hour  where  larger  quantities  are  not  re- 
tained. If  the  case  is  acute  it  may  be  necessary  to  secure  a 
wret-nurse.  Washing  out  the  stomach  and  gavage  are  two 
very  important  means  (which  should  not  be  forgotten)  of  treat- 
ing persistent  vomiting. 

Gavage,1  or  feeding  by  means  of  a  stomach-tube,  is  a 
method  used  in  various  diseases  and  conditions  of  infancv 
and  childhood.  In  cases  where  the  child  is  not  able  to  take 
nourishment,  or  only  an  insufficient  amount,  and  in  cases  of 

1  Battanis,  "  Forced  Feeding,"  Lancet,  June  16  and  23,  1883. 


112 


DISEASES  OF  INFANTS  AND  CHILDREN. 


uncontrollable  vomiting,  this  method  may  be  resorted  to.  It 
is  used  in  the  feeding  of  premature  infants,  whether  in  an 
incubator  or  not,  and  in  cases  of  small,  weak,  marantic 
ones,  who,  owing  to  weakness  or  lack  of  appetite,  do  not  take 
sufficient   nourishment.     It  is  also  employed  after  surgical 


Fig.  28.— The  practice  of  gavage  (De  Lee). 

operations  about  the  head  or  neck  where  swallowing  is  inter- 
fered with,  and  in  acute  diseases,  such  as  pneumonia,  in 
fevers,  and  delirium  or  coma. 

The  results  that  follow  this  method  of  feeding  are  surpri- 
sing, especially  in  cases  where  there  is  constant  vomiting  or 


INFANT  FEEDING  113 

where  the  stomach  has  a  very  small  capacity.  In  the  former 
case  the  vomiting  may  cease  and  the  food  be  retained ;  in  the 
latter,  the  capacity  of  a  stomach  that  previously  held  only 
an  ounce  or  two  may  rapidly  be  increased  until  an  average- 
sized  feeding  is  retained  with  ease. 

The  technic  of  the  method  is  simple,  and  the  procedure  con- 
ducted without  difficulty  in  children  under  two  years  of  age  ; 
above  that  age  it  may  be  difficult,  and  a  mouth-gag  may  be 
required;  in  some  cases  nasal  feeding  must  be  substituted. 
The  apparatus  employed  is  the  same  that  is  used  for  washing 
out  the  stomach,  and  since  it  is  frequently  desirable  to  wash 
out  the  stomach  before  introducing  the  meal,  the  same  tubing 
may  serve  for  both  purposes.  It  consists  of  a  soft  rubber 
catheter  connected,  by  means  of  a  piece  of  glass  tubing,  to  a 
piece  of  rubber  tubing,  to  the  other  end  of  which  a  funnel  is 
attached.  The  nurse  reclines  the  child  on  her  lap,  with  the 
head  held  straight — not  inclined  in  either  direction.  The 
catheter  is  moistened  with  warm  water  and  held  several 
inches  from  the  end,  so  as  to  allow  enough  of  it  to  pass  into 
the  esophagus  with  the  first  attempt  at  introduction.  The 
mouth  is  opened,  if  necessary,  and  the  catheter  passed 
rapidly  into  the  pharynx ;  there  is  usually  a  swallowing 
movement,  and  the  tube  is  readily  passed  into  the  stomach. 
If  the  procedure  is  carried  on  too  slowly,  the  tongue  may 
interfere,  or  if  the  catheter  is  held  too  near  the  end,  it  may 
cause  gagging.  Before  introducing  the  food  it  is  well  to  wash 
out  the  stomach  with  a  normal  salt  solution.  As  soon  as  all 
the  food  has  entered  the  stomach,  the  catheter  is  pinched  and 
rapidly  withdrawn.  If  it  is  withdrawn  slowly  the  food  may 
come  up  with  the  tube.  If  the  catheter  is  left  open  as  it  is 
withdrawn,  the  dripping  into  the  pharynx  may  cause  vomit- 
ing. If  the  child  is  young,  it  is  a  good  plan  to  keep  the 
finger  between  the  jaws  for  a  few  moments  to  prevent  gag- 
ging.    If  the  food  comes  up  the  feeding  must  be  repeated. 

Nasal  Feeding", — For  this  purpose  a  catheter  in  pro- 
portion to  the  size  of  the  child  should  be  used.  The  catheter 
is  well  oiled  and  passed  through  the  nostril  and  esophagus 
into  the  stomach. 

8 


114  DISEASES  OF  INFANTS  AND  CHILDREN. 


DISEASES   OF  NUTRITION. 

There  are  three  conditions  which  cannot  be  clearly  sepa- 
rated : 

Inanition j  a  condition  of  acute  starvation. 

Marasmus,  a  sub-acute  condition  but  a  very  serious  one. 

Malnutrition,  a  chronic  condition,  of  poor  assimilation. 
These  terms  are  often  interchanged  by  medical  writers. 

INANITION. 

Definition. — This  is  acute  starvation  due  to  insufficient 
or  improper  food.  It  is  most  often  seen  in  very  young  in- 
fants, but  may  also  be  met  with  in  the  older  ones. 

Etiology. — It  is  seen  where  the  child  gets  no  food  (as  in 
abandoned  infants) ;  where  the  supply  of  food  is  insufficient ; 
where  the  infant  refuses  to  nurse ;  where  the  food  is  suddenly 
changed,  and  where  the  food  is  not  adapted  to  the  infant's 
digestion,  and  where  the  infant's  digestion  is  too  weak  to 
utilize  the  food  supplied. 

Symptoms. — These  may  come  on  gradually  or  suddenly, 
or  the  onset  may  be  gradual  with  the  sudden  appearance  of 
severe  symptoms.  The  child  is  usually  under  three  months 
of  age,  and  the  most  striking  symptom  is  the  rapid  loss  in 
weight.  The  child  is  pale  or  cyanosed,  the  temperature  may 
be  subnormal,  or  there  may  be  fever.  The  fontanel  is  de- 
pressed. The  circulation  is  poor  and  the  respiration  irregu- 
lar. The  child  is  fretful  at  first,  but  later  may  become  com- 
atose. The  urine  is  scanty  and  low  in  chlorids.  There  is 
generally  some  disturbance  of  the  gastric  and  intestinal 
digestion,  and  often  vomiting  and  diarrhea. 

Prognosis. — This  is  usually  bad,  but  some  cases  recover 
if  properly  managed.  The  weight  and  general  appearance 
are  the  best  guides  as  to  how  the  child  is  doing.  The  pres- 
ence of  vomiting  or  diarrhea,  cyanosis,  very  high  fever,  or 
great  prostration  is  of  grave  significance.  The  duration  of 
the  disease  is  usually  a  few  days  or  a  week  or  two. 

Diagnosis. — This  is  made  on  the  absence  of  other  dis- 


DISEASES  OF  NUTRITION.  115 

eases  and  on  recognizing  the  cause.  Where  there  is  fever 
these  cases  may  be  mistaken  for  either  pneumonia  or  diarrhea. 
Fever  in  a  young  infant  should  always  lead  to  a  careful  in- 
quiry into  the  amount  and  character  of  food  taken. 

Treatment. — General  treatment  like  that  given  for  ma- 
rasmus. The  feeding  is  the  most  important  thing.  Br< -a-t 
milk  from  the  mother  or  a  wet-nurse  should  be  given,  either 
with  a  spoon,  medicine  dropper,  or  by  means  of  a  stomach 
tube.  The  milk  may  be  diluted  with  limewater,  and  if  very 
rich  the  cream  may  be  partly  removed  by  skimming.  If  a 
wet-nurse  is  not  obtainable,  whey,  peptonized  milk,  con- 
densed milk,  very  weak  modifications  of  milk,  malted,  fari- 
naceous gruels,  or  predigested-beef  preparations  may  be 
given. 

The  child  should  be  kept  warm,  or  if  there  is  fever,  this 
should  be  reduced  by  sponging  or  bathing.  Whiskv  or 
strychnin  or  both  may  be  administered  by  mouth  and,  if  they 
cause  vomiting,  by  rectum.  Oxygen  should  be  administered 
by  inhalation.  Normal  salt  solution  injections  into  the  rec- 
tum may  help  supply  the  lack  of  fluid  in  the  body. 

Infants  over  a  year  old  may  thrive  on  solid  food  where  all 
liquid  foods  are  refused  or  vomited. 

See  Management  of  Marasmus. 

MARASMUS.1 
(Athrepsia;  Simple  Atrophy ;  the  "Wasting  Disease  of  Infants.) 

Definition. — This  is  a  subacute  condition  where  there  is 
extreme  wasting,  usually  terminating  fatally.  It  is  due  to  the 
lack  of  ability  on  the  part  of  the  tissues  to  utilize  the  food 
taken. 

I£tiologry. — It  is  due  to  the  lack  of  proper  feeding,  lack 
of  fresh  air,  lack  of  care,  and  an  absence  of  "  mothering." 
Any  or  all  of  these  may  be  the  cause.  It  is  common  in 
overcrowded  institutions  for  infants,  and   infrequent  in  the 

1  A.  H.  "Wentworth,  "Atrophy,  Infantile,  Etiology  and  Dietetic  Treat- 
ment of,"  Journal  of  the  American  Medical  Association,  August  26,  1905, 
p.  579.  "Atrophic  Infants  and  Children,  Metabolism  in,*'  Journal  of  (he 
American  Medical  Association,  September  9,  1905,  p.  771. 


116  DISEASES  OF  INFANTS  AND   CHILDREN. 

country  or  in  private  practice  among  the  well-to-do.  In 
some  instances  the  child  is  congenitally  weak. 

Iyesions. — Great  wasting  of  the  muscles  and  body-fat 
and  an  atrophy  of  the  thymus  gland  are  the  only  constant 
lesions.  Atrophy  of  the  intestinal  mucosa  has  been  described. 
Secondary  lesions  such  as  pneumonia  may  be  found  where 
death  is  due  to  a  terminal  infection. 

Symptoms. — There  is  a  steady  loss  of  weight,  until  the 
child  is  reduced  to  mere  skin  and  bones,  and  the  skin  hangs 
in  folds  on  the  limbs.  The  cheeks  are  sunken  and  the  fon- 
tanel depressed.  The  abdomen  is  enlarged,  and  the  hands  and 
feet  are  like  claws,  so  that  these  children  suggest  young  birds 
in  appearance.  The  circulation  is  weak  and  respiration  feeble. 
The  temperature  is  usually  subnormal.  The  child  is  very  pale 
or  may  be  somewhat  cyanosed.  There  may  be  marked  digest- 
ive disturbance,  as  vomiting  and  diarrhea.  In  other  cases 
the  child  takes  its  nourishment  well  almost  to  the  time  of 
death.  There  is  usually  stiffness  of  the  muscles  in  the  severe 
cases  and  retraction  of  the  head.     The  course  of  the  disease  is 


Fig.  29.— Marasmus  with  purpura. 

weeks  or  months,  and,  as  a  rule,  the  children  become  weaker 
and  weaker  and  finally  sleep  away. 

Prognosis. — This  is  bad.  Cases  in  institutions  invari- 
ably die.  In  private  practice,  where  every  care  can  be  given, 
the  outlook  is  better. 

Diagnosis. — This  by  exclusion.  Care  should  be  taken 
not  to  mistake  tuberculosis  for  marasmus.  Several  careful 
examinations  should  always  be  made  before  a  final  diagnosis 
is  made. 

Treatment. — Plenty  of  fresh  air,  individual  care,  light, 


DISEASES  OF  NUTRITION.  117 

mid  "mothering."  Remove  to  the  country  where  possible. 
I)o  not  allow  the  infant  to  lie  in  the  crib  all  the  time.  It 
should  be  picked  up  and  carried  about.  It  should  never 
be  fed  in  the  crib,  but  on  the  nurses'  arm  or  lap.  It  should 
be  kept  warm.  Hot-water  bottles  may  be  used  or  the  child 
placed  in  an  incubator.  It  should  not  be  bathed  too  fre- 
quently. It  should  be  rubbed  gently,  twice  daily,  with  cocoa- 
nut  butter  or  some  bland  oil.  It  should  be  encouraged  to 
cry  sufficiently  to  expand  the  lungs. 

The  feeding  is  very  important.  A  wet-nurse  is  best. 
Next  to  that,  carefully  modified  milk  or  whey  mixtures  may 
be  used.  If  necessary  these  should  be  wholly  or  partially 
peptonized.     Predigested-beef  preparations  are  useful. 

Drugs  are  of  little  use,  but  small  doses  of  alcohol  or  con- 
densed milk  is  often  of  great  service.  Strychnin  sulphate, 
gr.  4^0,  or  atropin  sulphate,  gr.  10V0;  maJ  De  use&  where 
the  circulation  is  very  weak,  and  the  peptonate  of  iron  and 
manganese  Avhere  there  is  severe  anemia.  The  doses  should 
be  small,  and  if  digestion  is  interfered  with  the  drugs  should 
be  stopped.  Small  doses  of  thyroid1  (gr.  -J-j)  are  sometimes 
of  value,  but  should  be  used  with  caution. 

MALNUTRITION, 

Definition. — A  chronic  condition  in  which  there  are  no 
apparent  lesions,  but  a  decidedly  faulty  nutrition.  This  con- 
dition is  a  matter  of  months  or  more,  often  of  years. 

Etiology. — It  may  be  inherited  from  weak,  puerile,  or 
aged  parents,  and  where  there  is  an  alcoholic,  syphilitic,  gouty, 
or  tuberculous  taint  in  the  family.  It  may  result  from  some 
severe  disease  from  which  the  child  does  not  recover  its 
strength.  It  may  be  caused  by  lack  of  food,  fresh  air  and 
exercise. 

Symptoms. — These  children  are  small,  poorly  nourished, 

and  badly  developed.     They  are  under-sized,  under-weight, 

flabby,  pale,  and  anemic.     The  circulation  is  poor  and  they 

are  easily  chilled.     They  are  nervous,  sleep  badly,  and  are 

easily  tired  out.     Mentally,  the  older  children  may  be  very 

1  Simpson,  "  Thyroid  Treatment  in  Infantile  Wasting,"  British  Medical 
Journal,  April  30,  1910,  p.  1049.  "Thyroid  Gland  in  Relation  to  Marasmus," 
Scottish  Medical  and  Surgical  Journal,  Dec.,  1906,  p.  50-4. 


118  DISEASES  OF  INFANTS  AND  CHILDREN. 

bright.  Digestive  symptoms  are  common.  As  a  rule,  the 
appetite  is  poor  and  they  are  difficult  to  feed. 

Prognosis. — In  institutions  the  outlook  is  bad.  Where 
directions  can  be  fully  carried  out  many  cases  recover.  They 
usually  require  care  for  years. 

Diagnosis. — By  excluding  tuberculosis  and  other  dis- 
eases.    Several  careful  examinations  should  always  be  made. 


Fig.  30.— Malnutrition  after  intestinal  diarrhea. 

Treatment. — Careful  feeding,  as  directed  for  difficult 
cases,  if  the  child  is  an  infant,  or  along  the  lines  laid  down 
for  the  feeding  of  children.  Often  a  child  must  be  fed  in  a 
way  that  would  suit  a  healthy  child  of  half  the  age. 

Fresh  air,  country  life  where  possible,  exercise,  baths, 
massage,  rubbing  with  oil,  and  a  life  free  from  excitement 
are  indicated.     Regular  habits  are  very  important. 

Medicine  is  less  important  than  the  above.  Cod-liver  oil 
in  winter,  iron,  arsenic  and  occasionally  strychnia  and  alcohol 
are  indicated.     The  less  medicine  the  better. 

FOOD  INTOXICATIONS.1 

Definition. — A  form  of  auto-intoxication  due  to  taking 

more  food  than  can  be  properly  assimilated,  whether  too  much 

carbohydrate,  fat,  or  protein.     The  maximum  amounts  that 

can  be  utilized  normally  differ  greatly  in  different  individuals. 

Symptoms. — The  most  striking  feature  is  attacks  coming 

1  Ruhrah,  Journal  of  the   American  Medical  Association,  July  10,  1909, 
p.  105. 


DISEASES  OE  NUTRITION.  119 

on  periodically.  These  attacks  vary  in  their  character.  There 
may  be  vomiting  (see  Cyclic  Vomiting),  headaches,  recurring 
fever,  with  or  without  diarrhea,  asthma,  and  other  symptoms 
too  numerous  to  mention. 

Diagnosis. — Careful  physical  examination  to  exclude 
any  disease  of  any  organ,  and  this  having  been  done,  a  study 
of  the  child's  habits  and  food  should  be  made.  In  over 
half  the  cases  the  error  is  evident,  in  others  it  may  require 
trial  diets  to  determine  the  cause. 

Too  Much  Food  of  all  Kinds. — This  usually  causes  such 
attacks  as  are  called  biliousness.  There  is  fever,  a  coated 
tongue,  foul  breath,  headache,  malaise,  and  often  drowsiness. 
There  is  often  vomiting  or  diarrhea  or  both,  the  liver  may 
be  somewhat  enlarged  and  tender. 

Too  Much  Protein. — The  symptoms  are  as  in  the  preced- 
ing. Sometimes  one  symptom  is  especially  prominent,  as 
recurring  headache  or  attacks  of  vomiting,  or  in  milder  cases 
periods  when  the  tongue  is  furred  and  the  breath  foul  with- 
out much  other  disturbance. 

Too  Much  Fat. — The  child's  general  health  is  poor,  the 
skin  is  pale  and  muddy,  there  are  large  dark  circles  under  the 
eyes,  the  tongue  is  coated,  the  breath  is  exceedingly  fetid,  and 
there  is  frequently  gastric  disturbance  and  vomiting,  and  there 
is  often  diarrhea  with  the  passage  of  undigested  fat  in  the  stools. 

Too  Much  Carbohydrate. — This  is  the  most  frequent  form, 
owing  to  the  fact  that  many  children  are  given  large  quanti- 
ties of  starches  and  sugars.  Recurring  attacks  of  vomiting, 
diarrhea  with  fever,  often  headache,  or  asthma  are  the  most 
frequent  symptoms. 

Prognosis. — Where  the  co-operation  of  the  parent  can 
be  secured  the  results  are  usually  satisfactory. 

Treatment. — The  intestinal  tract  should  be  cleaned  out 
with  a  brisk  purge  and  occasional  doses  of  phosphate  of  soda 
given.  The  diet  should  be  carefully  regulated  to  suit  the 
child's  age  and  condition.  Where  any  special  class  of  foods 
is  at  fault,  it  should  be  reduced  to  the  minimum. 

ACID  INTOXICATION. 

Disturbances  of  metabolism  are  characterized  by  the  pres- 
ence in  the  urine  of  acetone  and  oxybutyric  acid.  This  may 
be  caused  in  children  by  many  things  :  starvation  changes  in 


120 


DISEASES   OF  INFANTS  AND   CHILDREN. 


the  diet,  infectious  diseases,  especially  pneumonia,  late  in 
diabetes,  poisoning  by  salicylic  acid,  and  as  a  sequela  of 
anesthetics.  In  cyclic  vomiting  (see  same)  it  is  also  present. 
In  milder  cases  symptoms  are  slight  or  absent.  In  the  severe 
cases  there  is  a  more  or  less  comatose  condition,  loss  of  eye- 
ball tension,  slow  deep  breathing,  sometimes  called  air-hunger, 
and  usually  marked  and  persistent  vomiting.  The  diacetic 
acid  is  present  in  the  urine. 

Treatment. — Some  forms  of  sugar,  particularly  glucose, 
by  rectum  or  even  subcutaneously,  and  sodium  bicarbonate 
by  mouth  or  by  rectum. 

RACHITIS  (Rickets).1 

Definition. — Rickets  is  a  constitutional  disease  caused 
bv  faulty  feeding  and  improper  hygiene.     The  bones  show 

the  principal  changes,  but  almost 
all  the  tissues  of  the  body  are  af- 
fected. 

etiology. — Rickets  is  usu- 
ally seen  in  artificially  fed  chil- 
dren, rarely  in  the  breast-fed.  It 
is  primarily  caused  by  a  food  too 
low  in  fats  and  proteins.  Such 
foods  usually  contain  an  excess 
of  carbohydrate  material.  Rickets 
may  be  experimentally  produced 
in  young  animals  by  such  food. 
In  addition,  however,  in  human 
beings  there  seem  to  be  other 
factors  in  its  causation,  such  as 
bad  hygiene,  particularly  over- 
crowding. Rickets  is  seen  in  the 
temperate  zones  and  most  often  in 
Southern  races  which  have  moved 
to  the  North.  In  the  United  States 
it  is  especially  common  among  the 
negroes  and  the  Italians. 

1  James, "  Late  Rickets,"  Scottish  Medical  awl  Surgical  Journal,  January, 
1897.  William  Ewart,  "Rickets,  Abdominal  Atony  in,  its  Significance  and 
Treatment,"  British  Medical  Journal,  October  13,  1906,  p.  920.  R.  W.  Mars- 
den,  "  Rickets,  Late,"  Edinburgh  Medical  Journal,  vol.  xvii.,  1905,  p.  344. 


Fig.  31.— Rickets. 


DISEASES  OF  NUTRITION.  121 

I/esions. — The  bone  changes  are  the  most  striking.  The 
growth  of  the  epiphyseal  cartilages,  especially  in  the  long 
bones,  is  rapid  and  excessive,  and  there  is  a  similar  process  in 
the  production  of  cells  beneath  the  periosteum.  Ossification 
takes  place  slowly  and  irregularly.  Instead  of  the  bone  con- 
taining about  two-thirds  mineral  matter  and  one-third  ani- 
mal matter,  the  composition  is  about  one-third  mineral  mat- 
ter and  two-thirds  animal  matter.  The  bones  are  deformed 
and  soft.  After  from  three  to  fifteen  months  the  pathologic 
process  in  the  bone  stops. 

Other  lesions  frequently  seen  are  enlargement  of  the  spleen 
and  lypmph  glands  and  catarrhal  conditions  of  the  mucous 
membranes. 

Symptoms. — Rickets  comes  on  usually  between  the  sixth 
and  fifteenth  month.     It  may,  however,  be  seen  earlier. 

In  the  early  cases,  and  especially  so  in  young  infants,  the 
early  symptoms  are  great  restlessness  at  night,  sweating, 
especially  about  the  head,  beading  of  the  ribs,  craniotabes, 
and  constipation. 

After  a  short  time  the  disease  becomes  well  developed. 
The  following  conditions  may  be  noted.  As  a  rule  not  all  of 
them  are  present  in  any  one  case. 

The  head  is  large,  the  bones  of  the  skull  thickened,  the 
fontanels  remain  open  late,  and  the  union  of  the  sutures  is 
delayed.  The  head  is  generally  square  and  shows  deform- 
ities in  about  one-third  of  the  cases.  Craniotabes,  a  crackling 
sensation  produced  by  slight  pressure  of  the  fingers  over  the 
parietal  and  occipital  bones  and  due  to  thinning  of  the  bones 
in  spots,  is  rarely  seen  after  six  months.  It  is  also  found  in 
syphilis.     Dentition  is  delayed  and  irregular. 

The  lymph-glands  all  over  the  body  are  enlarged.  The 
mucous  membranes  are  relaxed  and  catarrhal  condition-  are 
frequent. 

The  chest  shows  enlargement  of  the  ribs  at  the  junction 
of  the  bone  with  the  cartilages,  the  so-called  rickety  rosary. 
The  chest  is  frequently  deformed  by  vertical  and  transverse 
sulci.  There  may  be  a  funnel  breast.  The  ribs  often  flare 
at  the  bottom.  There  may  be  kyphosis  of  the  dorsal  spine ; 
lordosis  may  also  be  present. 


122 


DISEASES  OF  INFANTS  AND  CHILDREN. 


The  abdomen  is  enlarged,  and  the  child  is  pot-bellied. 
This  is  due  to  deficient  tone  in  the  intestinal  and  abdominal 
muscles.  Constipation  is  associated  with  this.  The  spleen 
is  enlarged.  The  children  are  flabby  and  weak.  They  are 
generally  under-sized,  under-developed,  and  walk  late. 

The  blood  is  more  or  less  normal,  although  anemia  may  be 
present,  due  to  other  causes. 


Fig.  32.— Rickets. 


Fig.  33.— Rickets. 


The  most  marked  changes  are  seen  in  the  long  bones. 
They  are  bent,  irregular  in  shape,  and  usually  have  marked 
thickening  of  the  ends  about  the  epiphyses.  The  tibia  and 
fibula  and  radius  and  ulna  show  the  most  marked  deform- 
ities.    The  pelvis  may  be  deformed. 

Kachitic  children  are  usually  nervous  and  convulsions  are 
common. 


DISEASES  OF  NUTRITION.  123 

After  an  active  stage  of  several  months  the  process  sub- 
sides and  the  child  generally  recovers.  The  deformities 
remain  for  years  and  may  never  disappear. 

Prognosis. — As  far  as  life  is  concerned  it  is  good,  and 
with  proper  treatment  the  cases  eventually  do  well.  Rachitic 
children  are  liable  to  convulsions,  bronchitis,  pneumonia,  their 
resistance  is  generally  lowered,  and  they  are  liable  to  die  with 
intercurrent  affections. 

Diagnosis. — As  a  rule  this  is  easy.  Syphilis  shows 
other  symptoms  of  the  disease,  and  the  shafts  of  the  bones 
are  affected  rather  than  the  epiphyses.  Syphilitic  bones  are  apt 
to  break  down.  Xecrosis  is  never  seen  in  uncomplicated 
rickets.  Antisyphilitic  treatment  helps  to'  differentiate  ob- 
scure cases.  Rickets  of  a  severe  type  must  be  separated  from 
actual  paralysis.  The  reflexes  are  preserved  and  the  muscle 
can  be  stimulated  to  move.  Scurvy  is  differentiated  by  the 
cardinal  svmptoms  of  scurvy  and  antiscorbutic  treatment. 

Treatment. — Good  hygiene  and  proper  food  are  essen- 
tial. Fresh  milk  properly  modified,  fresh  meat  juice,  cream 
or  other  fat  should  be  added  to  the  dietary.  Eggs,  fresh 
meat,  vegetables,  and  fruit  for  older  children.  Cod-liver  oil 
and  olive  oil  are  the  best  medicaments.  Phosphorus  has 
been  advised  in  yttS*-  doses.  Iron,  hypophosphites,  and 
arsenic  may  also  be  used. 

The  deformities  should  be  treated  by  orthopedic  means. 

ADOLESCENT  RACHITIS. 

This  is  regarded  as  a  recrudescence  of  a  condition  which 
existed  in  infancy,  occurring  about  puberty,  due  to  a  dis- 
turbance in  nutrition  at  the  time  of  great  bone  activity.  The 
pathologic  and  histologic  changes  approach  those  seen  in 
the  infantile  type.  In  general  the  symptoms  resemble  the 
infantile  type,  but  the  acute  form  is  rare,  and  the  local 
changes  are  more  marked  than  the  general.  In  girls  scoliosis 
is  the  most  common  deformity,  while  in  boys  disturbance  in 
the  legs  is  most  frequently  observed.  Changes  in  the  cranium 
are  rarely  seen. 


124  DISEASES  OF  INFANTS  AND   CHILDREN. 

SCURVY.1 

(Scorbutus;  Barlow's  Disease*) 

Definition. — A  constitutional  disease  due  to  errors  of 
diet,  characterized  in  infants  by  hemorrhages  from  the  mucous 


Fig.  34.— Infantile  scurvy:  Characteristic  attitude  of  the  legs  (Northrup  and 

Bovaird). 

membranes  and  under  the  skin,  by  swelling  and  pain  about 
the  larger  joints,  by  an  ulcerative  stomatitis,  and  a  severe 
anemia.     It  is  frequently  associated  with  rickets. 

Etiology. — Food  which  is  not  fresh  seems  to  be  the 
causal  factor.  The  American  Pediatric  Society  found  that 
the  kind  of  food  used  in  the  cases  reported  was  as  follows  : 

111  American  Pediatric  Society  Report,"  Archive*  of  Pediatrics,  July, 
1898,  p.  481.  J.  L.  Morse,  "  Scorbutus,  Infantile,"  Journal  of  the  American 
Medical  Association,  April  14,  1906,  p.  1073.  G.  F.  Still.  'Scurvy,  Infan- 
tile," British  Medical  Journal,  July  28,  1906,  p.  186. 


DISEASES   OF  NUTRITION. 


125 


Proprietary  infant  food,  sterilized  milk,  condensed  milk,  pas- 
teurized milk,cows5  milk  unboiled,  breast  milk.  Theformerare 
common,  and  the  latter  rare,  causes.  The  use  of  the  improper 
diet  usually  covers  a  period  of  several  month.-.     The  greatest 

number  of  eases  are  between  seven  and  ten  months  of  age. 

lyesions.  —  Hemorrhages,  especi- 
ally under  the  periosteum,  about  the 
large  joints,  and  hemorrhages  else- 
where and  changes  in  the  blood-ves- 
sels, are  the  common  findings.  Other 
changes  are  aiven  under  the  head  of 
symptoms. 

Symptoms. — The  child  becomes 
anemic,  sometimes  cachectic  in  appear- 
ance, and  it  is  fretful  and  irritable. 
Pain  in  one  or  more  joints  is  one  of 
the  earliest  manifestations.  The  gums 
-well  and  bleed  readily,  and  sooner  or 
later  there  is  an  ulcerative  stomatitis. 
There  is  a  great  tendency  to  hemor- 
rhage, and  this  may  take  place  almost 
anywhere,  as  nosebleed,  hemorrhage 
from  the  stomach  or  bowel,  or  any  of 
the  mucous  membranes.  There  may 
be  hematuria.  Hemorrhages  may  take 
place  under  the  skin,  and  ecchymoses 
(black  and  blue  spots)  may  be  noted, 
especially  about  the  larger  joints.  There 
may  be  effusion  or  hemorrhage  into  the  larger  joints,  causing 
swelling,  or  it  may  be  under  the  periosteum  or  between  the 
muscle?,  causing  swellings.  These  are  liable  to  be  symmetric. 
Hemorrhage  into  the  orbit  may  cause  protrusion  of  the  eye. 
There  may  be  edema  or  ecchymoses  of  the  eyelid.  There 
may  be  pseudoparalyses,  and  separation  of  epiphyses  is  not 
uncommon  in  advanced  cases.  There  may  be  edema,  espe- 
cially of  the  extremities.      Slight  fever  is  not  uncommon. 

Diagnosis. — The  character  of   food   is   important,  and 
scurvy  should  alwavs  be  borne  in  mind  when  there  is  a  his- 


Fig.  35.— Vertical  section 
of  the  thigh  and  leg  in  a 
case  of  infantile  scorbutus. 
The  dark  areas  along  the 
femur  and  tibia  represent 
subperiosteal  hemorrhage 
(W.  P.  Xorthrup). 


126  DISEASES  OF  INFANTS  AND   CHILDREN. 

tory  of  an  absence  of  fresh  food.  Rheumatism  is  rare  under 
one  year  of  age,  yet  the  pain  and  swelling  most  often  lead 
to  the  erroneous  diagnosis  of  that  disease.  Scurvy  may  be 
mistaken  for  sarcoma,  osteomyelitis,  or  abscess,  acute  anterior 
poliomyelitis,  or  other  joint  or  spinal  disease.  If  separation 
of  the  epiphysis  occurs  it  may  be  mistaken  for  fracture.  It 
may  be  confused  with  nephritis.  Antiscorbutic  treatment 
clears  up  the  diagnosis  in  almost  all  cases. 

Prognosis. — Good  if  seen  early ;  poor  if  seen  very  late. 
Untreated  cases  usually  end  fatally. 

Treatment. — A  proper  diet  and  the  administration  of 
fresh  fruit  juice.  One-half  to  three  or  four  ounces  of  orange 
juice  a  day,  given  in  four  or  five  doses.  Fresh  ripe  peach 
juice,  grape  juice,  or  lemon  juice  may  be  substituted.  For 
older  children  the  addition  of  fresh-beef  juice  and  potato  is 
of  service. 

DIABETES  MELLITUS.1 

Definition. — A  symptom  complex,  the  most  marked 
symptoms  being  glycosuria,  polyuria,  increased  thirst,  and  a 
progressive  loss  of  weight. 

Btiology. — Rare  in  infancy  and  childhood.  Undoubted 
cases  have  been  reported  as  early  as  four  months.  The  ten- 
dency to  the  disease  increases  with  age.  Heredity  is  marked 
as  a  cause.  Blows  on  the  head  may  precipitate  the  disease. 
Too  much  starch  and  sugar  may  bring  it  on  where  there  is  a 
predisposition. 

Pathology. — Not  clear.  Lesions  have  been  found  in 
the  floor  of  the  fourth  ventricle,  and  in  the  pancreas. 

Symptoms. — Polyuria  is  marked,  more  during  the  day 
than  at  night.  From  1  to  5  liters  or  more  may  be  excreted 
daily.  The  child's  napkins  must  be  changed  twenty  or  thirty 
times  a  day.  Enuresis  is  frequent.  Thirst  is  marked.  The 
appetite  is  usually  ravenous.  Mouth  and  tongue  are  dry  ;  the 
gums  bleed  easily.  Constipation  is  usually  present.  Skin  is 
dry  and  scaly  and  frequently  eczematous.  Furunculosis  and 
pruritus  are  common.     Edema  may  be  present. 

1  Stern,  Archives  of  Pediatrics,  June,  1902,  p.  425,  and  Aug.,  1904,  p.  617. 


DISEASES  OF  NUTRITION.  127 

The  wasting  is  rapid  and  marked.  Headache  and  neural- 
gia are  common.  Patellar  reflexes  may  be  diminished  or 
absent.  The  child  becomes  irritable  and  capricious.  Insom- 
nia is  marked.     There  may  be  blindness  or  diabetic  cataract. 

The  disease  comes  on  suddenly  and  runs  a  rapid  course, 
lasting  usually  a  few  weeks  or  months,  although  it  may  last  a 
year  or  two.  Death  is  from  pneumonia-  tuberculosis,  or 
coma. 

Diabetic  Coma. — There  may  be  prodromes,  a  sweetish  chlo- 
roform-like odor  to  the  breath  and  diacetic  acid  in  the  urine. 
There  is  apathy  and  then  loss  of  consciousness.  The  pupils 
are  fixed  and  equal,  either  dilated  or  contracted ;  patellar  re- 
flexes are  lost.  Temperature  may  be  lowered  or  sometimes 
raised.  Pulse  rapid  and  breathing  irregular  and  sighing. 
Child  becomes  algid  and  cyanotic  and  death  takes  place  in 
from  eighteen  to  thirty-six  hours.     • 

Urine  in  Diabetes. — As  in  adults.  Specific  gravity, 
1.030  to  1.040  ;  marked  glycosuria  ;  and  there  maybe  acetone 
or  diacetic  acid  in  the  urine. 

Diagnosis. — From  diabetes  insipidus,  lactosuria,  and  ali- 
mentary glycosuria. 

Prognosis. — Always  bad. 

Treatment. — Dietetic  measures  are  rarely  tried  with  dia- 
betic children,  owing  to  the  hopelessness  of  the  condition. 
They  should,  however,  be  given  a  trial.  Feed  on  proteid  food, 
fats,  and  alcohol.  Reduce  starches  and  sugars  or  absolutely 
prohibit  them.  v.  x^oorden's  oatmeal  cure  may  be  tried. 
(AYell-cooked  oatmeal,  to  which  vegetable  or  egg  albumin 
and  butter  has  been  added ;  alcohol  is  also  allowed.  Meat  or 
vegetables  allowed  once  a  week.  Gradually  return  to  regular 
diet.)  Soy  beans  in  combination  with  an  otherwise  carbo- 
hydrate-free diet  may  reduce  the  amount  of  sugar  in  the 
urine. 

Prophylactic  Diet. — In  diabetic  families  the  amount  of 
carbohydrate  food  should  be  limited. 

Drugs. — The  following  are  a  few  of  those  recommended  : 
morphin,  codein,  bromid  of  potassium,  antipyrin,  and  lacto- 
phosphate  of  lime. 


128  DISEASES  OF  INFANTS  AND   CHILDREN. 


DISEASES  OF  THE  MOUTH  AND  PHARYNX.1 

PERLECHE.     (Lemaistre,  1886.) 

A  grayish-white   ulceration,   usually  at   the  angle  of  the 
lips,  caused  by  constant  licking.     It  may  be  confused  with  a 


Fig.  36.— Double  harelip  and  cleft  palate.  The  prominence  on  the  left  side  of 
the  deformity  shows  the  protruding  intermaxillary  bone,  with  the  slcin  of  the 
median  line  of  the  lip  covering'  it  (skin  of  frontonasal  process)  (Eisendrath). 

syphilitic   mucous  patch.     Burnt  alum  or  nitrate  of  silver 
should  be  used  with  antiseptic  washes  and  dusting  powders. 

HARELIP.2 

Due  to  incomplete  fusion  of  one  or  both  lateral  processes 
to  the  central  process  in  the  development  of  the  face.     May 

1  Mayer,  "  Affections  of  the  Mouth,  Throat,"  etc.,  American  Journal  of 
the  Medical  Sciences,  1902. 

2  G.  V.  I.  Brown,  "  Hare-lip  and  Cleft  Palate,  Surgical  Correction  of," 
Journal  of  the  American  Medical  Association,  March  18,  1905,  p.  848. 


DISEASES  OE  THE  MOUTH  AND  PHARYNX.       129 

be  single  or  double.     Interferes  with  sucking  and  is  an   un- 
sightly deformity. 

Operation  should  be  performed.  Opinions  differ  as  to  the 
best  time  to  operate.  In  simple  eases  it  may  be  performed 
alter  one  month,  and  the  more  serious  ones  after  six  months. 

CLEFT  PALATE.1 

This  is  frequently  associated  with  harelip.  The  children 
are  generally  weakly  and  apt  to  die  from  inanition  or  inter- 
current affections.      Great  care  in   feeding  and  great  cleanli- 


Fig.  37.— Macroglossia  (Dandridge). 

ness  about  the  mouth  are  required.  Feeding  may  be  done 
with  a  spoon,  a  long  medicine  dropper,  or  by  a  stomach  tube. 
The  mouth  should  be  frequently  swabbed  with  a  mild  anti- 
septic solution. 

Operations  should  be  deferred  until  the  child  is  from  two 
to  six  years  old,  according  to  the  general  condition  and  the 
severity  of  the  deformity. 

1  Brown,  Journal  of  the  American  Medical  Association,  March  18,  1905. 
9 


130  DISEASES  OF  INFANTS  AND  CHILDREN. 

CONGENITAL  HYPERTROPHY  OF  THE   TONGUE. 

This  is  due  to  disease  of  the  lymphatics,  and  demands  sur- 
gical treatment.  It  should  not  be  confused  with  the  pro- 
truding tongue  of  the  cretin. 


OTHER  DEFORMITIES. 

Tongue-tie. — This  is  due  to  the  frenum  extending  to 
the  tip  of  the  tongue,  holding  it  down,  and  interfering  with 
speech  and  sometimes  with  sucking.  Inability  to  speak 
may  depend  solely  on  this  cause.  It  should  be  divided  with 
the  scissors  and  separated  to  the  normal  length  by  pressing 
back  with  the  fingers. 

Bifid  tongue  and  bifid  palate  may  be  met  with. 

EPITHELIAL  DESQUAMATION  OF  TONGUE. 

Acute  Forms. — The  margins  of  the  tongue  are  red ; 
the  center  white.  The  red,  or  denuded,  parts  of  the  tongue 
advance  in  crescentic  areas  until  the  entire  tongue  is  red. 
Lasts  several  weeks. 

Chronic  Form. — The  epithelium  desquamates  slowly 
and  irregularly.  The  denuded  patch  is  red  and  is  bounded 
by  a  crescentic  white  line  of  white  and  thickened  epithelium. 
The  remainder  of  the  tongue  is  normal.  These  lines  of 
desquamation  move  about  over  the  tongue.  It  lasts  months 
or  years,  is  of  no  importance  and  requires  no  treatment.  It 
is  often  a  cause  of  worry  to  mothers. 

GLOSSITIS. 

Acute  swelling  of  the  tongue  may  occur  in  urticaria. 

Inflammation  of  the  tongue  may  occur  from  infection — 
usually  from  a  tooth.  Local  inflammations,  with  thickening 
of  the  tongue,  are  common  from  the  same  cause. 

Treatment. — Liquid  food,  nasal  feeding  if  necessary. 
Cold  mouth-washes  or  ice  in  the  mouth.  If  interfering  with 
respiration,  scarification  or  needle  punctures. 


DISEASES  OF  THE  MOUTH  AND  PHARYNX.       131 

TONGUE    SWALLOWING. 

May  occur  in  pertussis  and  other  conditions.  If  not  relieved 
may  cause  death  by  interfering  with  respiration.  In  weak 
infants  the  tongue  may  fall  back  into  the  pharynx  and  cause 
asphyxia. 

ULCER   OF   THE   FRENUM. 

This  is  usually  seen  in  weakly  infants,  and  especially  in 
those  who  have  pertussis  or  some  other  form  of  cough.  It 
is  caused  by  the  central  incisors  coming  in  contact  with  the 
tongue.  Burnt  alum  or  nitrate  of  silver  application  is  usually 
efficient. 

RIGA'S   DISEASE. 

This  is  a  rare  condition  where  there  is  an  ulcerated  papil- 
loma of  the  frenum.  It  is  an  indolent  ulcer,  quite  hard,  and 
covered  with  a  grayish  false  membrane.  It  requires  surgical 
treatment. 

ALVEOLAR   ABSCESS. 

This  comes  from  decayed  teeth,  and  causes  great  swelling 
at  the  side  of  the  face  and  of  the  jaw.  The  abscess,  of  its  own 
accord,  generally  breaks  into  the  mouth.  It  may  open  exter- 
nally or  into  the  nose  or  antrum,  or  it  may  cause  necrosis  of 
the  bone,  and  open  into  the  maxillary  sinus.  Decayed  teeth 
should  be  filled  or  drawn,  and  an  antiseptic  mouth-wash  used 
to  prevent  abscess.  When  it  has  already  formed  it  should  be 
opened  and  treated  like  any  other  abscess. 

DIFFICULT  DENTITION.1 

Roughly  speaking,  about  one-third  of  all  infants  cut  their 
teeth  without  any  trouble,  about  one-third  have  slight  disturb- 
ance of  their  general  health,  while  the  remaining  third  are  made 
really  ill  by  the  cutting  of  each  tooth.  Sometimes  one  tooth 
will  cause  trouble,  while  others  do  not.  Before  making  a 
diagnosis  of  difficult  teething  a  most  careful  examination 
should  be  made.     The  following  symptoms  may  at  times  be 

1  L.  Guthrie,  "  Dentition,  Primary,  Disorders  Associated  with,"  Practi- 
tioner, October,  1905,  p.  547. 


132  DISEASES  OF  INFANTS  AND   CHILDREN. 

caused  by,  or  accompany,  difficult  teething :  Restlessness, 
sleeplessness,  fever,-  stomatitis,  vomiting  and  diarrhea,  en- 
largement of  the  cervical  glands,  eczema  and  urticaria,  bron- 
chitis, and  convulsions;  this  last  especially  in  rickety  chil- 
dren. 

Treatment. — If  the  gum  is  swollen  and  the  tooth 
nearly  through,  the  former  may  be  lanced  ;  rubbing  it  with 
a  silver  thimble  or  with  the  finger  covered  with  gauze  may 
give  relief.  A  dose  of  calomel  often  relieves  the  fever  or 
gastro-intestinal  symptoms.  The  restlessness  and  sleepless- 
ness may  be  relieved  by  rubbing  the  gum  with  a  drop  or 
two  of  paregoric,  or  applying  sodium  bromid  in  solution 
with  a  little  glycerin,  or  by  the  internal  use  of  bromids,  or 
of  bromids  and  chloral,  or  of  bromids  and  phenacetin,  or 
codein  and  antipyrin. 

DISEASES  OF  THE  UVULA. 

Uvulitis. — This  is  rare.  There  is  swelling,  elongation, 
and  edema  of  the  uvula.  There  is  an  irritating  cough,  and 
there  may  be  interference  with  swallowing.  Ice  in  the 
mouth,  needle  puncture,  and  astringent  applications  are 
indicated. 

Elongated  Uvula. — This  is  probably  congenital,  but  is 
increased  by  repeated  inflammations.  There  is  an  irritating 
cough  and  often  asthmatic  attacks  on  lying  down.  Diagnosis 
is  made  by  inspection.  A  small  amount  of  the  uvula  should 
be  cut  off. 

BEDNAR'S    APHTHAE. 

There  are  two  symmetric  ulcerations  over  the  hamular 
process  of  the  palate  bone.  The  mucous  membrane  at  this 
point  has  poor  circulation,  owing  to  frequent  stretching  every 
time  the  pterygomaxillary  muscle  is  contracted,  as  in  opening 
the  mouth.  Any  abrasion  of  the  mucous  membrane  at  this 
point,  as  by  rough  washing  of  the  mouth,  results  in  an 
intractable  ulceration. 

Treatment. — Touch  twice  daily  with  10  per  cent,  silver 
nitrate  solution  and  keep  the  mouth  clean. 


DISEASES  OF  THE  MOUTH  AND   PHARYNX.       133 

CATARRHAL  STOMATITIS. 

This  is  caused  by  taking  irritating  or  overheated  things 
into  the  mouth,  and  is  also  present  as  a  complication  of  many 
of  the  infectious  diseases  and  in  teething. 

There  is  redness  and  swelling  of  the  mucous  membrane 
with  an  increased  flow  of  mucous  and  saliva.  There  may 
be  slight  swelling  of  the  tongue  and  lips.  The  cervical 
glands  are  slightly  enlarged,  and  there  is  some  pain  on 
taking  food. 

Treatment. — Keep  the  mouth  clean  by  using  antiseptic 
and  mildly  astringent  washes.  If  food  is  refused  give  it 
cold.  If  any  ulcerations  occur  powdered  burnt  alum  may 
be  applied. 

HERPETIC  STOMATITIS. 

(Aphthous  Stomatitis;  Vesicular  Follicular  Stomatitis.) 

This  is  caused  by  herpetic  eruption  (fever  blisters)  in  the 
mouth.  The  top  of  the  little  vesicle  is  rubbed  off  and  a 
small  round  or  oval,  punched-out  ulcer  with  bright-red  edges 
and  a  white  base  remains.  It  is  common  after  the  first  year. 
The  ulcers  are  over  the  tongue  and  also  on  the  cheeks,  and 
come  on  in  successive  crops.     They  are  very  painful. 

Diagnosis. — From  diphtheria,  which  it  may  somewhat 
resemble  if  several  ulcers  coalesce,  and  from  Koplik  spots. 

Treatment. — Apply  burnt  alum  or  touch  with  nitrate  of 
silver  and  use  antiseptic  mouth  washes. 

THRUSH.1 

(Sprue;  Soor;  Muguet.) 

This  is  a  form  of  stomatitis  due  to  the  growth  of  a  fungus 
(the  Saccharomyces  albicans,  Grawitz)  in  the  mouth.  It  is 
most  frequently  seen  in  the  mouths  of  nursing  infants  where 
there  is  a  lack  of  cleanliness.  It  rarely  affects  other  parts  of 
the  body. 

It  occurs  as  white  flakes  or  crusts  which  look  like  milk 

1  Langford  Syrnes,  International  Medical  Magazine,  vol.  iii.,  No.  12. 


134  DISEASES  OF  INFANTS  AND  CHILDREN 

seen  in  the  mouth  immediately  after  feeding.  It  cannot, 
however,  be  wiped  off,  and  when  it  is  removed  leaves  some 
bleeding-points. 

The  diagnosis  is  easy.  The  fungus  may  be  easily  de- 
monstrated under  the  microscope.  The  outlook  is  good,  but 
in  very  weak  infants  it  may  interfere  with  the  taking  of 
food. 

Treatment. — Cleanliness  regarding  nipples,  nursing-bot- 
tles, and  everything  which  comes  in  contact  with  the  infant. 
Nipples  should  be  kept  in  boric  acid  solution.  Cleanse  the 
mouth  carefully  but  gently,  before  and  after  feeding,  with  some 
mild  antiseptic  mouth-wash.  Where  this  does  not  relieve  it 
paint  the  mouth  with  a  boric  acid  solution  or  a  solution  of 
protargol  (3  per  cent.)  three  or  four  times  a  day  and  feed  by 
gavage. 

ULCERATIVE  STOMATITIS. 

Definition. — An  ulceration  of  the  mouth  starting  on  the 
gums  at  the  edges  of  the  teeth  and  spreading  to  the  other 
tissues. 

Etiology. — It  is  seen  only  in  children  with  teeth.  It 
occurs  in  mercurial,  lead,  and  phosphorus  poisoning,  in  scurvy, 
from  uncleanliness,  and  also  in  children  who  are  weak  and  run- 
down in  health. 

Symptoms. — The  ulcers  are  covered  with  a  yellowish- 
gray  deposit,  the  gums  are  swollen,  congested,  and  bleed 
easily.  The  teeth  may  loosen  and  fall  out.  Necrosis  of  the 
jaw  may  occur.  There  is  a  very  foul  odor  to  the  breath 
and  profuse  salivation.  The  cervical  glands  are  swollen, 
tender,  and  may  suppurate.  As  a  rule,  there  is  marked  con- 
stitutional disturbance  consisting  of  high  fever,  loss  of  appe- 
tite, malaise,  and  the  like. 

Diagnosis. — The  condition  is  self-evident.  The  cause 
should  be  sought. 

Prognosis. — Good  with  proper  care  and  treatment.  If 
neglected  it  may  prove  fatal. 

Treatment.  — Remove  cause  when  known.  In  scurvy  give 
fresh  fruit  and  proper  diet,  and  in   all  cases  keep  the  mouth 


DISEASES  OF  THE  MOUTH  AND  PHARYNX.       135 

clean  with  antiseptic  mouth-washes.  Peroxid  of  hydrogen 
(1  :  4),  permanganate  of  potassium  (1  :  4000),  or  a  saturated 
solution  of  chlorate  of  potassium  are  the  most  satisfactory. 
Burnt  alum  or  nitrate  of  silver  may  be  used  to  hasten  the 
healing  of  the  ulcerations. 

Internally,  chlorate  of  potassium  is  almost  specific.  Two 
grains  (half  a  teaspoonful  of  the  saturated  solution)  may  be 
given  hourly  for  the  first  day  and  every  two  hours  for  one  or 
two  more  days.  It  should  be  well  diluted.  The  urine  should 
be  watched.  Later,  acids  and  iron  should  be  used  with  gen- 
eral building-up  treatment.  The  diet  should  in  all  cases  be 
antiscorbutic  and  as  nourishing  as  possible. 

GANGRENOUS  STOMATITIS, 

(Cancrum  Oris;  Noma.)1 

Definition. — A  form  of  gangrene  seen  in  children,  usually 
in  the  mouth,  but  also  affecting  other  mucocutaneous  orifices, 
as  the  vulva,  anus,  prepuce,  the  external  auditory  canal  or 
the  nose. 

Etiology. — It  is  rare  and  is  seen  usually  in  institution 
children  and  almost  always  follows  an  attack  of  some  of  the 
infectious  diseases,  as  measles  or  scarlet  fever.  It  is  appar- 
ently contagious,  but  no  one  organism  has  been  described  as 
the  cause,  although  many  have  been  mentioned  as  the  etio- 
logic  factors. 

Symptoms. — It  begins  as  a  small  discolored  spot  on  the 
lip  or  cheek.  This  is  hard  and  becomes  rapidly  larger.  It 
soon  becomes  black  and  breaks  down  at  the  center  with  the 
formation  of  a  dark  necrotic  mass  which  has  a  very  offensive 
odor  which  may  be  the  first  thing  noted.  There  is  edema 
of  the  cheek,  and  the  gangrene  spreads  rapidly.  The  teeth 
loosen  and  fall  out,  and  the  jaws  necrose.  The  cheek  may 
be  perforated,  and  most  of  the  face  may  slough  away.  There 
is  little  or  no  pain.     There  may  be  high  temperature,  which 

1  Bloomer  and  Macfarland,  American  Journal  of  the  3Iedical  Sciences, 
November,  1901.  "  Noma,"  British  Medical  Journal,  April  15, 1909,  p.  473. 
Neuhof,  "  An  Epidemic  of  Noma,"  American  Journal  of  the  Medical  Sciences, 
vol.  cxxxix.,  1910,  p.  705. 


136  DISEASES  OF  INFANTS  AND   CHILDREN. 

grows  less  as  the  child  weakens.  The  child  is  apathetic  and 
dull ;  may  be  almost  comatose.  There  is  muscular  relax- 
ation and  often  diarrhea. 

Diagnosis. — This  is,  as  a  rule,  easy. 

Prognosis. — The  disease  lasts  from  a  week  to  ten  days, 
and  death  occurs  in  three-fourths  or  more  of  the  cases. 

Treatment. — Radical  early  treatment  is  the  only  hope. 


Fig.  38.— Gangrenous  stomatitis. 

The  diseased  area  may  be  removed  by  excision  or  by  actual 
cautery.  Another  method  of  treatment  is  to  cleanse  with 
peroxid  and  then  paint  twice  daily  with  a  10  per  cent, 
chromic  acid. 

Injections  of  carbolic  acid  may  be  made  around  the  entire 
area,  a  little  outside  of  the  gangrene.  Nitric  acid  may  be 
injected  into  the  mass.  Antistreptococcic  and  antidiphtheritic 
serum  have  been  used  with  benefit  in  some  cases.  The  fre- 
quent use  of  antiseptic  washes  is  required.  The  cases  should 
be  isolated. 

OTHER  FORMS  OF  STOMATITIS. 
Stomatitis  may  occasionally  be  caused  by  the  gonococcus, 
the  diphtheria  bacillus,  and  other  organisms.     A  syphilitic 
stomatitis  is  also  seen. 


DISEASES   OF  THE  MOUTH   AND   PHARYNX.       137 

DISEASES  OF  THE  TONSILS.1 

Acute  catarrhal  tonsillitis  is  >v^n  in  acute  pharyngitis,  but 
rarely  alone. 

CROUPOUS  TONSILLITIS. 

This  is  a  more  severe  form  in  which  there  is  a  fibrinous 
exudate  which  first  tills  the  crypts  and  then  spreads  over  the 
entire  tonsil,  usually  affecting  both  sides.  The  exudate  pro- 
duces a  grayish-yellow  film  (which  can  be  swabbed  off  with- 
out any  bleeding-points)  over  the  tonsil.  The  streptococcus 
is  usually  present.  Symptoms  and  treatment  like  follicular 
tonsillitis. 

Diagnosis. — From  diphtheria  by  the  high  fever  and 
that  it  may  be  wiped  off  without  leaving  bleeding-points. 

ULCEROMEMBRANOUS  TONSILLITIS    Vincent,  1896). 2 

A  process  similar  to  ulcerative  stomatitis  caused  by  Vin- 
cent's bacillus.  It  is  often  unilateral.  There  is  a  dirty -gray 
false  membrane  with  superficial  ulceration.  The  breath  is 
very  foul,  as  in  ulcerative  stomatitis,  with  which  it  may  be 
associated.  The  lymph  glands  at  the  angle  of  the  jaw  are 
swollen.  There  is  no  constitutional  disturbance  of  any 
moment. 

Diagnosis. — From  diphtheria  by  means  of  bacteriolog- 
ical examination,  by  absence  of  constitutional  symptoms. 

Treatment. — Chlorate  of  potassium  internally,  as  in 
ulcerative  stomatitis,  the  local  application  of  nitrate  of 
silver,  and  the  use  of  antiseptic  mouth-washes. 

FOLLICULAR  TONSILLITIS. 

Definition. — An  inflammation  of  the  entire  tonsil  where 
the  crypts  are  filled  with  plugs  of  exudate.  The  constitu- 
tional disturbance  is  very  great  for  the  small  amount  of  local 
trouble. 

1  G.  B.  Wood,  "  Tonsils,  Lymphatic  Drainage  of,"  American  Journal  of  (he 
Medical  Sciences,  Aug.,  1905,  p.  216.    Chapin,  Medical  News,  V(  >1.  lxxiv. .  Xo  9. 

2  Sobel  and  Hermann,  New  York  Medical  Journal,  December  7,  1901. 


138 


DISEASES  OF  INFANTS  AND   CHILDREN. 


Etiology. — Rare  in  infants,  but  common  during  child- 
hood. Frequent  attacks  in  the  same  child.  Often  associated 
with  the  presence  of  rheumatism.  The  staphylococcus  and 
the  streptococcus  can  usually  be  found  in  the  exudate. 

Pathology. — Acute  swelling  and  congestion  of  the  whole 
tonsil,  with  an  exudate  plugging  up  the  crypts,  and  some- 
times a  fibrinous  exudate  covering  the  remainder  of  the  tonsil, 
but  not  extending  beyond  it. 

Symptoms. — On  inspection  the  tonsils  are  seen  to  be 
swollen  and  the  crypts  filled  with  yellowish  plugs,  which 
may  be  pressed  out,  and  sometimes  there  is  a  film  of  exudate 


Fig.  39.— Acute  infectious  pseudomembranous  tonsillitis  (follicular)  :  The  two 
whitish  points  on  the  posterior  wall  represent  exudate  formed  on  isolated  muco- 
lymphoid  follicles  (Casselberry). 


(which  can  be  wiped  off  with  a  swab)  over  the  tonsil.  Both 
sides  are  affected. 

There  is  sudden  onset,  often  with  a  chill,  followed  by  high 
fever,  which  may  be  104°  or  105°  F.  There  is  headache, 
backache,  and  pains  in  the  limbs.  There  may  be  vomiting 
and  diarrhea,  especially  in  young  children.  The  glands  at 
the  angle  of  the  jaw  are,  as  a  rule,  not  much  enlarged,  and 
the  throat  is  not  very  painful.  The  symptoms  gradually  grow 
better  and  disappear  in  three  or  four  days. 

Diagnosis. — From  diphtheria,  scarlet  fever,  influenza, 
pneumonia,  and  malaria.     By  inspection  of  the  throat  and 


DISEASES  OF  THE  MOUTH  AND  PHARYNX.       139 

the  presence  or  absence  of  the  signs  and  symptoms  of  these 
diseases  (which  see). 

Prognosis. — Good. 

Treatment. — Relieve  the  pain  by  using  phenacetin  or 
antipyrin  and  codein.  Give  salicylate  of  sodium  where  there 
is  a  history  of  rheumatism.  Give  effervescing  draught  or 
lime  water  and  cinnamon  water  to  relieve  nausea.  Antiseptic 
mouth-washes  may  be  used. 

PHLEGMONOUS  TONSILLITIS. 

(Peritonsillar  Abscess ;  Quinsy.) 

Definition. — A   unilateral   inflammation   of  the  tissues 

about  the  tonsil,  and  often  of  the  tonsil  itself,  which  usually 

suppurates,  but  which  may  go  on  to  resolution.     Sometimes 

it  may  extend  to  the  pharyngeal  wall.     It  is  rare  in  children. 


Fig.  40.— Peritonsillar  abscess  :  a,  Point  for  puncture  (Casselberry). 

Etiology. — Exposure  or  excesses.  Infection  with  pus- 
forming  bacteria. 

Symptoms. — Like  follicular  tonsillitis  as  regards  general 
symptoms,  but  less  intense  the  first  day,  and  increasing  as  the 
disease  progresses. 

There  is  pain  in  the  throat,  difficult  swallowing,  and  pain 
on  opening  the  mouth.  There  may  be  tenderness  externally. 
On  the  first  or  second  day  little  can  be  seen  which,  with  the 


140  DISEASES  OF  INFANTS  AND  CHILDREN. 

presence  of  symptoms  of  sore  throat,  is  extremely  suggestive. 
After  one  or  two  days  there  is  marked  swelling  in  and  about 
the  tonsil,  and  the  uvula  may  be  pushed  to  one  side.  Fluc- 
tuation may  be  made  out  after  the  first  few  days.  If  left 
alone  the  abscess  forms  and  breaks,  as  a  rule,  inside  of  a 
week. 

Treatment. — Salol  in  rather  large  doses  may  be  given 
if  the  case  is  seen  early.  Phenacetin  and  codein  may  be 
given  to  relieve  the  pain.  Hot  or  cold  applications,  which- 
ever is  more  grateful  to  the  patient,  may  be  used.  Open  as 
soon  as  fluctuation  is  well  determined.  Eelief  after  opening  is 
usually  immediate. 

CHRONIC  HYPERTROPHY  OF  THE  TONSILS. 
(Chronic  Tonsillitis.) 

Definition. — A  general  enlargement  of  the  tonsil.  Both 
the  lymphoid  tissue  and  the  connective  tissue  are  increased — 
all  grades  are  met  with.  The  degree  of  hardness  depends  on 
the  amount  of  connective  tissue  present. 

Etiology. — Associated  with  adenoids  ;  also  in  "  lymph- 
atism."  It  is  found  in  certain  families.  It  is  quite  a  com- 
mon affection. 

Symptoms. — Similar  to  those  produced  by  adenoids, 
with  which  this  condition  is  usually  associated.  Difficulty 
in  swallowing  and  disturbed  sleep  may  be  troublesome. 

Diagnosis. — By  inspection,  when  the  enlarged  tonsils 
can  be  readily  made  out. 

Prognosis. — After  puberty  they  atrophy  somewhat. 

Treatment. — If  sufficiently  enlarged  to  cause  symptoms 
they  should  be  removed  by  using  a  tonsillotomy.  Syrup  of 
the  iodid  of  iron  is  a  useful  tonic  for  these  children. 

RETROPHARYNGEAL  ABSCESS.1 

There  are  two  forms  :  The  idiopathic  abscess  of  infancy, 
and  that  secondary  to  Caries  of  the  vertebra?. 

1  Ripley,  Archives  of  Pediatrics,  February,  1884,  p.  104. 


DISEASES  OF  THE  MOUTH  AND  PHARYNX.       141 

Idiopathic  Abscess. — This  is  a  suppuration  of  the 
retropharyngeal  lymph  nodes  and  is  the  same  process  as  that 
described  as  the  acute  adenitis  of  infants. 

Etiology. — Three-fourths  of  the  cases  occur  under  one  year 
of  age.  They  follow  rhinitis,  pharyngitis,  or  the  acute  in- 
fectious diseases. 

Symptoms. — There  is  usually  a  history  of  an  attack  of  one 
of  the  above.  A  week  or  two  later  there  are  fever  and  con- 
stitutional disturbance.  The  cause  of  this  may  not  at  first 
be  apparent.  Local  symptoms  soon  make  their  appearance. 
These  are  dyspnea,  which  may  be  mostly  inspiratory  and 
most  marked  on  lying  down ;  difficulty  in  swallowing  and 
refusal  to  nurse ;  regurgitation  of  the  food  through  the  nose  ; 
there  may  be  cough  and  a  nasal  character  to  the  voice;  there 
may  be  complete  aphonia.  Snoring  is  noted.  The  head  is 
thrown  back  and  torticollis  may  be  the  first  symptom  ob- 
served. There  is  an  abscess  swelling,  to  be  made  out  by 
inspection  or  palpation,  in  the  back  of  the  pharynx,  and  it 
may  also  be  apparent  just  below  the  angle  of  the  jaw  to  the 
front  of  the  sternomastoid  muscle. 

Diagnosis. — By  digital  examination  of  the  pharynx,  which 
should  be  made  in  every  case  where  there  is  dyspnea.  Ke- 
traction  of  the  head  with  dyspnea,  difficult  swallowing,  and 
mouth-breathing  are  the  principal  symptoms.  Exclude  sar- 
coma. 

Prognosis. — This  is  fairly  good  if  the  diagnosis  is  made. 
The  abscess  may  open  itself.  Death  may  result  from 
asphyxia  or  from  rupture  during  sleep,  when  the  pus  may 
block  the  larynx,  or  from  a  secondary  pneumonia  or  septi- 
cemia. 

Treatment. — Hot  applications  to  the  throat  until  fluctua- 
tion can  be  ascertained,  and  then  open  immediately.  Opening 
through  the  mouth  is  ordinarily  to  be  preferred,  but  some- 
times it  can  be  opened  to  advantage  externally. 

Retropharyngeal  Abscess  from  Pott's  Disease. — 
This  is  similar  to  the  above,  but  comes  on  very  slowly,  and 
generally  there  are  symptoms  of  Pott's  disease  for  some  time 
before  there  is  any  abscess.  They  do  not  heal  promptly  as 
the  idiopathic  abscesses  do,  but  leave  a  suppurating  sinus. 


142  DISEASES  OF  INFANTS  AND   CHILDREN. 

The  diagnosis  is  made  by  digital  examination.  The  opening 
should  be  made  externally,  just  below  the  jaw  and  in  front  of 
the  sternomastoid  muscle. 

ACUTE  PHARYNGITIS. 

Definition. — An  inflammation  of  the  pharynx  which 
may  be  primary  or  may  occur  as  a  part  of  some  other  disease, 
especially  the  exanthems. 

Symptoms. — There  is  at  first  dryness  of  the  throat; 
later  redness,  swelling,  edema,  and  increased  secretion.  There 
is  pain  at  the  angle  of  the  jaw,  which  is  increased  on  swal- 
lowing.    The  cervical  lymphatics  are  slightly  enlarged. 

There  is  fever,  from  100°  to  103°  F.  or  even  higher,  and 
there  may  be  considerable  malaise.  The  symptoms  generally 
pass  off  in  a  day  or  two. 

Diagnosis. — Measles  may  generally  be  distinguished  by 
Koplik  spots  and  the  other  catarrhal  symptoms.  Scarlet 
fever  cannot  be  excluded  until  sufficient  time  has  elapsed  to 
be  sure  there  will  be  no  rash.  Influenza  can  be  told  by  the 
presence  of  the  other  catarrhal  and  constitutional  symptoms. 

Treatment. — Open  the  bowels  with  calomel  or  castor  oil. 
Rest  in  bed,  liquid  diet,  ice  to  suck,  and  an  effervescing 
draught  if  there  is  vomiting.  Phenacetin  or  codein  and 
antipyrin  can  be  used  if  there  is  much  pain  or  nervousness. 

RETROESOPHAGEAL  ABSCESS.1 
A  rare  condition  due  to  Pott's  disease  or  to  breaking  down 
of  the  retro-esophageal  lymph  nodes.  Symptoms  are  dyspnea, 
often  spasmodic,  and  usually  most  marked  on  inspiration. 
There  may  be  spasmodic  cough  and  a  change  in  the  voice. 
Most  cases  die  from  pressure  on  the  pneumogastric  or  from 
rupture.  Rupture  into  the  esophagus  may  rarely  result 
favorably. 

INFLAMMATION  OF    THE  ESOPHAGUS. 
The  esophagus  is  seldom  diseased.     Diphtheria  may  very 
rarely  extend  into  it  from  the  pharynx.     Lacerations  due  to 
1  Griffith,  Archives  of  Pediatrics,  January,  1898,  p.  1. 


DISEASES  OF  THE  MOUTH  AND  PHARYNX.       143 

swallowing  rough  or  sharp  objects  usually  heal  promptly. 
Ulcers  are  rare  in  early  life.  Catarrhal  inflammations  from 
swallowing  hot  or  irritating  food  cause  slight  pain  on  swal- 
lowing.    This  form  heals  in  a  few  days. 

Corrosive  Ksophagitis. — This  is  comparatively  fre- 
quent and  results  from  the  child  drinking  lye  or  strong  acids. 
If  the  patient  survives  the  poison,  extensive  ulceration  re- 
mains, which  gradually  heals,  leaving  large  scars.  These 
gradually  contract,  producing  stricture  of  the  esophagus. 
The  immediate  symptoms  are  severe  burning,  great  thirst, 
inability  to  swallow,  or  great  difficulty  and  pain  on  swallow- 
ing. Edema  of  the  glottis  may  prove  fatal.  Symptoms  of 
stricture  come  on  after  several  months  or  years.  The  treat- 
ment of  the  stricture  is  surgical,  generally  consisting  of  the 
passing  of  bougies,  although  some  cases  are  amenable  to 
operation. 

MALFORMATIONS  OF  THE   ESOPHAGUS.1 

These  are  of  various  kinds.  Fistulse  may  open  into  the 
trachea  or  through  the  neck.  The  esophagus  may  be  absent, 
end  in  a  blind  pouch,  or  be  strictured  or  constricted. 

Many  of  these  deformities  may  be  corrected  by  surgical 
operation.  Complete  obstruction  is  always  fatal.  The  symp- 
toms are  vomiting  after  a  very  small  amount  of  food  has 
been  taken  and  inability  to  pass  a  stomach-tube. 

1  Marsh,  American  Journal  of  the  Medical  Sciences,  August,  1902,  p.  304. 


144  DISEASES  OF  INFANTS  AND  CHILDREN. 

DISEASES  OF  THE  STOMACH. 

VOMITING. 

Vomiting  is  an  exceedingly  common  symptom  in  infancy 
and  may  be  due  to  the  following  causes  : 

1.  Overfilling  the  stomach. 

2.  Outbursts  of  anger. 

3.  Stricture  or  obstruction  in  the  esophagus. 

4.  Acute  gastric  indigestion. 

5.  Pyloric  stenosis. 

6.  Acute  intestinal  obstruction. 

7.  Appendicitis  and  peritonitis. 

8.  Acute  infectious  diseases,  especially  at  the  onset. 

9.  Fever  from  almost  any  cause  in  infants  may  be  accom- 
panied by  vomiting. 

10.  Brain-pressure,  as  in  acute  meningitis  and  brain  tumor. 

11.  Any  persistent  prolonged  cough,  but  especially  whoop- 
ing-cough. 

12.  Toxic.  From  the  accumulation  of  poisons  in  the  blood, 
as  in  cyclic  vomiting,  uremia,  the  absorption  of  ptomaines 
from  the  intestinal  tract,  etc. 

13.  Reflex  irritation  of  the  pharynx,  as  in  sucking  the 
hands. 

14.  Habit. 

Chronic  vomiting  is  generally  xlue  to  habit  or  to  chronic 
indigestion. 

The  treatment  depends  on  the  cause. 

CYCLIC  VOMITING.1 

Definition. — Attacks  of  vomiting  lasting  several  days, 
uninfluenced  by  any  known  treatment,  and  recovering  spon- 
taneously. The  attacks  come  on  at  regular  or  irregular  in- 
tervals without  any  apparent  cause. 

Etiology. — It  may  begin  as  early  as  two  years  of  age. 

1  Shaw",  Archives  of  Pediatrics,  November,  1902,  p.  825.  Shaw  and  Tribe, 
"  Recurrent  Vomiting,"  British  Medical  Journal,  February,  1905,  p.  347.  F. 
Langmead,  "Vomiting,  Recurrent,  of  Children,"  British  Medical  Journal, 
February  18,  1905,  p.  350. 


DISEASES  OF  THE  STOMACH.  145 

The  sexes  arc  affected  equally.     Sometimes  fatigue  or  excite- 
ment may  seem  to  precipitate  an  attack. 

Pathology. — This  is  unknown,  although  the  condition 
is  apparently  an  auto-intoxication,  usually  an  acid  intoxica- 
tion. The  urine  gives  evidence  of  congestion  of  the  kid- 
neys, and  also  contains  indican  and  acetone,  and  usually 
diacetic  acid.  Holt  and  Herter  point  out  that  there  is  a  dis- 
turbance of  the  ratio  of  uric  acid  and  urea  excreted.  Nor- 
mally it  is  about  1  to  54.  In  Holt's  case  it  was  1  to  1  52 
on  the  second  day  of  the  attack. 

Symptoms. — There  are  often  prodromes  for  a  day  or  less, 
consisting  of  languor,  headache,  and  malaise,  and  then  the  vom- 
iting begins  suddenly  and  is  forcible  and  distressing.  There 
may  be  slight  temperature.  The  violent  repeated  vomiting  causes 
great  exhaustion  and  the  child  lies  in  an  apathetic  condition. 
There  is  great  thirst.    The  abdomen  is  sunken  and  not  tender. 

Prognosis. — Usually  good,  although  occasionally  a  case 
ends  fatally.  The  vomiting  ceases  spontaneously  after  a  few 
days.  Toward  puberty  the  attacks  become  less  frequent  and 
may  stop  altogether. 

Diagnosis. — Meningitis,  brain  tumor,  nephritis,  acute  in- 
digestion, intussusception,  and  appendicitis  must  be  excluded. 

Treatment. — Calomel  at  the  outset  if  seen  before  vomit- 
ing starts.  After  it  begins  nothing  can  be  done  to  stop  it, 
although  large  doses  (3i-ij)  of  sodium  bicarbonate,  given  by 
rectum,  sometimes  seem  to  shorten  the  attack.  Give  enemata 
of  water  every  four  or  five  hours  and  nutrient  enemata  when 
the  case  lasts  over  three  days.  When  the  vomiting  stops, 
food  may  be  cautiously  given,  albumin-water,  barley-water, 
and  milk  and  lime-water.  Convalescence  is  rapid.  Between 
the  attacks  a  carefully  regulated  out-of-door  life  with  a  diet 
in  which  there  is  a  lessened  amount  of  sugar  and  starch, 
giving  plenty  of  milk,  eggs,  meats,  green  vegetables,  and 
stale  bread.     (See  Auto-intoxication.) 

GASTRALGIA. 
Severe  pain  in  the  abdomen,  which  may  be  due  to  a  num- 
ber of  causes.     It  recurs  frequently  in   some  children  and 
causes  great  distress.     It  may  be  due  to  indigestion,  to  cold 

10 


146  DISEASES  OF  INFANTS  AND  CHILDREN. 

feet,  to  chronic  malaria,  to  drinking  iced  water,  and  in  some 
cases  apparently  to  irregular  contraction  of  the  intestines. 
Severe  abdominal  pain  may  also  be  caused  by  dorsal  Pott's 
disease,  pneumonia,  diaphragmatic  pleurisy  and  various  dis- 
eases of  the  abdominal  organs. 

Treatment. — Rest  in  bed.  Keep  the  child  warm  if 
chilled.  Hot  applications  over  the  epigastrium,  using  either 
a  hot  water  bottle,  mustard  plaster  or  turpentine  stupes. 
Spirits  of  chloroform  in  five-drop  doses  with  the  compound 
tincture  of  cardamom  given  in  very  hot  water  usually  gives 
prompt  relief.  Tincture  of  ginger,  brandy  and  gin  in  hot 
water  are  also  much  used.  A  few  drops  of  peppermint  in 
water  is  a  frequent  household  remedy. 

In  the  interval  a  correct  diet,  careful  hygiene,  and  in  the 
frequently  recurring  attacks  mix  vomica  or  Fowler's  solution 
of  arsenic  may  be  given. 

ACUTE  GASTRIC  INDIGESTION.1 

Etiology. — Usually  from  errors  in  diet,  the  use  of  indi- 
gestible, stale  or  unsuitable  food.  Frequently  seen  in  other 
forms  of  illness  from  continuing  diet  suitable  for  health,  but 
not  for  the  weakened  condition.  It  may  be  caused  by  ex- 
posure, overheating,  and  in  infants  from  difficult  teething. 

Symptoms. — Pain  and  discomfort  in  the  stomach  fol- 
lowed by  eructation  or  vomiting.  There  is  distention  of  the 
abdomen  in  most  cases.  There  is  usually  fever  which  may 
be  alarmingly  high.  There  are  often  marked  nervous  symp- 
toms such  as  dulness  or  even  stupor  or  extreme  restlessness 
and  often  convulsions.  These  usually  disappear  promptly 
with  proper  treatment. 

Diagnosis. — From  acute  gastritis  and  other  conditions 
mentioned  as  causing  vomiting. 

Prognosis. — Good  in  previously  healthy  children.  Weak 
children  sometimes  do  badly.  Death  may  be  caused  in  either 
case  from  convulsions. 

Treatment. — Empty  the  stomach  and  keep  it  at  rest. 
In  infants  wash  out  the  stomach ;  in  older  children  give  a 

1  Clarke,  "  Gastric  Digestion  in  Infants,"  American  Journal  of  Medical 
Sciences,  vol.  cxxxvii.,  1909,  p.  674. 


DISEASES  OF  THE  STOMACH.  117 

large  quantity  of  warm  water  and  induce  vomiting.  "With- 
hold  all  food  for  half  a  day,  when,  if  the  stomach  is  quiet,  a 
little  albumin-water  may  be  given.  Egg-water  or  whey  may 
be  substituted  if  desired.     On  the  second  day  the  same  may 

be  given  with  the  addition  of  weak  broths.  After  a  day  or 
two  longer,  if  all  goes  well,  peptonized  or  malted  milk  may  be 
given  or  equal  parts  of  milk  and  barley-gruel  boiled  together. 
If  the  child  is  breast-fed  take  it  off  the  breast  for  a  day  and 
feed  albumin-water  or  barley-water.  The  following  day 
nursing  may  be  allowed  for  a  few  minutes  at  a  time  and 
albumin-water  and  plain  boiled  water  given  in  addition.  The 
nursing  time  may  be  gradually  increased. 

Calomel  may  be  given  in  small  doses  until  the  bowels 
move  freely.  After  that  equal  parts  of  lime-water  and  cin- 
namon-water may  be  given  in  teaspoonful  doses  to  allay  the 
nausea.  Chalk  mixture  or  small  doses  of  bismuth  may  be 
used  in  place  of  the  above  if  it  is  necessary.  Heat  over  the 
epigastrium  is  grateful  ;  a  hot  water  bag,  mustard  plaster, 
spice  bag  or  turpentine  stupes  may  be  used. 

ACUTE  GASTRITIS. 

Definition. — An  acute  inflammation  of  the  stomach. 
Usually  seen  as  a  part  of  a  gastro-enteritis,  rarely  uncom- 
plicated. There  is  a  catarrhal,  a  membranous,  and  an  ulcera- 
tive form. 

I^esions. — There  is  hyperemia  of  the  stomach-wall  and 
a  marked  increase  in  the  mucus  secreted.  The  glands  are 
swollen  and  the  stomach-wall  infiltrated  with  an  inflamma- 
torv  exudate.  In  the  membranous  form  there  is  a  false 
membrane  similar  to  that  seen  in  diphtheria.  It  may  be 
caused  by  true  diphtheria,  pseudo-diphtheria  or  occasionally 
complicating  membranous  entero-colitis.  In  the  ulcerative 
form  there  are  one  or  more  small  ulcerations.  Various 
forms  of  bacteria  have  been  found  in  cases  of  gastritis.  ^  Gas- 
tritis due  to  taking  irritant  poisons  produces  changes  similar 
to  those  found  in  corrosive  esophagitis. 

Symptoms. — Similar  to  acute  gastric  indigestion,  but 
more  severe,  more  prolonged,  and  often  there  is  vomiting  of 


148  DISEASES  OF  INFANTS  AND  CHILDREN 

blood,  especially  in  the  ulcerative  form.  The  membranous 
form  presents  no  especial  symptoms. 

Diagnosis. — It  is  impossible  to  distinguish  it  from  acute 
gastric  indigestion  at  the  outset. 

Prognosis. — Usually  good,  except  in  the  corrosive  form, 
which  is  usually  fatal. 

Treatment. — Wash  out  the  stomach  and  give  it  rest. 
Diet  and  drugs  as  in  acute  gastric  indigestion.  Bicarbonate 
of  soda  or  other  alkalis  may  be  given.  Bismuth  is  one  of 
the  most  efficient  drugs. 

CHRONIC  GASTRIC  INDIGESTION. 
(Chronic  Gastric  Catarrh;  Chronic  Gastritis.) 

Definition. — The  symptoms  of  these  conditions  are  about 
alike  and  they  may  be  grouped  together. 

Etiology. — Repeated  attacks  of  acute  gastric  indigestion, 
or  the  continued  use  of  improper  food,  may  cause  it,  or  it 
may  be  a  complication  of  other  diseases. 

Pathology. — -There  is  infiltration  of  the  stomach-wall, 
and  in  rare  instances  the  presence  of  considerable  connective 
tissue. 

Symptoms. — There  are  lessened  digestive  ability,  in- 
creased mucus,  fermentation,  and  motor  insufficiency.  There 
are  also  vomiting,  regurgitation  of  food,  acid  eructations, 
distention  of  the  stomach,  and  pain.  Tongue  is  coated  ;  the 
appetite  varies ;  there  is  restlessness  and  sooner  or  later 
malnutrition. 

Prognosis. — Good  under  favorable  surroundings  and 
where  proper  treatment  can  be  carried  out.  Bad  where  they 
cannot  be  properly  managed. 

Treatment. — In  Infants. — Good  hygiene  is  essential. 
Wash  the  stomach  once  a  day,  or  oftener,  if  necessary. 
Proper  food.  (See  Infant  Feeding.)  The  meals  must  be 
smaller  than  recommended  for  a  normal  child  and  at  greater 
intervals.  Drugs  are  of  little  value.  Hydrochloric  acid  and 
pepsin  may  be  given.  For  eructations,  if  they  continue  after 
stomach  washing,  grain  doses  of  sodium  salicylate  may  be  given. 

Older  Children. — Large  quantities  of  hot  water  with  bicar- 


DISEASES  OF  THE  STOMACH. 


149 


bonate  of  soda  in  it  or  Vichy  water,  may  be  taken  slowly 
on  rising  and  an  hour  before  each  meal. 

Diet. — Milk  which  has  been  diluted  with  a  carbonated 
water,  lime-water  or  peptonized  milk,  koumiss,  and  rare 
meat  should  be  given  at  the  outset.  Then  the  following anay 
be  added  one  after  the  other  :  Zwieback,  toast,  stale  bread, 


Fig.  41.— Stomach,  showing  ulcers  and  pseudomembranous  exudation  (Wollstein). 

spinach,  well-cooked  cauliflower  tops,  asparagus  tops,  young 
peas  (mashed),  young  green  string  beans,  well-baked  mealy 
potato  (in  small  quantity).  Later  on,  vegetables  and  more 
starchy  food. 

Prohibit  all  undigestible  articles  (see  List,  page  101). 

Drugs. — Nux  vomica  or  some  other  bitter  tonic  before 
meals,  and  hydrochloric  acid  after  meals,  are  usually  all  that 
are  needed.  The  peptonate  of  iron  may  be  used  if  there  is 
anemia. 

DILATATION  OF  THE  STOMACH. 

This  may  be  seen  even  in  young  infants,  especially  a 
moderate  degree  with  chronic  gastritis.  There  are  usually 
symptoms  of  gastric    indigestion    and    motor    insufficiency. 


150  DISEASES  OF  INFANTS  AND  CHILDREN. 

The  stomach  is  distended  and  can  often  be  seen  through  the 
abdominal  walls.  The  size  may  be  determined  by  giving 
water  and  percussing  the  lower  border  of  the  stomach.  If 
it  is  near  the  umbilicus  it  is  dilated.  The  size  may  also  be 
measured  by  filling  the  stomach  with  water  and  withdrawing 
it  with  a  stomach  tube. 

Diagnosis. — Usually  easy,  from  physical  signs.  Exclude 
dilated  colon. 

Prognosis. — Good  if  properly  treated,  bad  if  not.  Bad 
in  pyloric  stenosis. 

Treatment. — Smaller  meals  at  greater  intervals  and 
treat  the  indigestion.     Nux  vomica  is  the  most  useful  drug. 

CONGENITAL  STENOSIS  OF  THE  PYLORUS.1 

Definition. — This  is  a  congenital  hypertrophic  stenosis 
of  the  pylorus. 

Pathology. — The  condition  is  congenital  and  the  lesion 
consists  of  a  funnel-shaped  thickening  of  the  pylorus.  The 
stomach  is  dilated  in  most  cases,  and  the  intestines  are  empty 
and  collapsed. 

Symptoms. — There  are  vomiting,  constipation,  and  a 
progressive  loss  of  weight.  The  dilatation  of  the  stomach 
can  usually  be  demonstrated.  The  gastric  peristaltic  move- 
ments can  be  seen.     The  thickened  pylorus  can  often  be  felt. 

Diagnosis. — This  may  be  difficult.  In  wasting  infants 
with  chronic  vomiting  unrelieved  by  the  treatment  of  a  skilled 
pediatrician,  the  condition  should  always  be  suspected. 

Prognosis. — Practically  all  cases  die  unless  treated  surgi- 
cally.    About  50  per  cent,  recover  with  operation. 

Treatment. — Three  operations  have  been  tried.  Gastro- 
enterostomy, Loreta's  operation  of  forcibly  dilating  the 
pylorus,  and  pyloroplasty.  The  last  has  thus  far  given  the 
best  results.  If  operation  is  impossible,  systematic  washing 
of  the  stomach  may  be  tried. 

1  Scudder  and  Quinby,  Journal  of  the  American  Medical  Association,  May 
27,  1905,  p.  1665.  Thomson,  "Pyloric  Hypertrophy,"  Scottish  Medical 
and  Surgical  Journal,  June,  1897,  p.  511.  Fischer  and  Sturmdorf,  "Pyloric 
Stenosis,"  Archives  of  Pediatrics,  May,  1906,  p.  341. 


DISEASES  OF  THE  STOMACH.  151 

ULCER  OF  THE  STOMACH.1 

This  is  rare  in  infa  nts  and  young  children.  It  may  1  >e  seen  in  the 
hemorrhagic  disease  of  the  newborn,  in  acute  gastritis,  in  tuber- 
culosis, and  there  is  an  idiopathic  form  which  tends  to  perforate 

Symptoms. — Pain,  tenderness,  vomiting  (often  with 
blood),  bloody  stools  (black).  If  perforation  occurs  peri- 
tonitis follows. 

Diagnosis. — Forms  cannot  be  distinguished.  The  above 
symptoms  are  characteristic. 

Prognosis. — Bad  in  most  cases.  Death  may  be  due  to 
perforation  or  to  hemorrhage. 

Treatment. — Rest  in  bed  for  at  least  three  weeks,  longer 
if  necessary.  Hot  fomentations  may  be  used  if  there  is 
much  pain  or  tenderness.  Small  frequent  feedings  are  best, 
as  a  rule.  Bismuth  subnitrate  may  be  used  in  large  doses. 
If  perforation  occurs,  immediate  operation. 

TUMORS  OF  THE  STOMACH. 

Carcinoma,2  sarcoma,  and  lymphadenorna  have  been  reported 
in  infants  and  young  children.     They  are  all  very  rare. 

HEMATEMESIS. 
(Hemorrhage  from  the  Stomach.) 

This  may  be  caused  by  the  following :  The  hemor- 
rhagic disease  of  the  newborn,  ulcer  of  the  stomach,  acute 
gastritis,  the  swallowing  of  blood  from  the  nose  or  pharynx, 
and  in  nursing  infants,  blood  from  a  fissured  or  ulcerated 
nipple,  hemophilia,  purpura,  the  purpuric  forms  of  the  infec- 
tious diseases,  scurvy,  and  in  young  girls  about  puberty  from 
vicarious  menstruation. 

If  the  blood  is  immediately  ejected  it  may  be  bright  red 
in  color.  If  it  has  been  in  the  stomach  any  length  of  time  the 
color  is  dark  and  it  is  grumous.     The  stools  are  a  tarry  black. 

If  from  a  lesion  in  the  stomach  keep  at  rest,  and  give 
adrenal  extract.  Do  not  feed  by  the  mouth,  but  by  the  rec- 
tum for  a  day  or  two. 

i  "  Gastric  Ulcer  in  the  Young,"  New  York  Med.  Jour.,  Oct.  3, 1909,  p.  837. 
2  Osier  and  McOae,  New  York  Med.  Jour.,  April  21,  1900,  p.  581. 


152  DISEASES   OF  INFANTS  AND   CHILDREN 

DISEASES  OF  THE  INTESTINES, 

MALFORMATIONS  OF  THE  INTESTINES. 

There  may  be  stenosis  or  atresia  at  any  point  in  the  intes- 
tinal canal.  The  lesions  are  frequently  multiple  and  usually 
at  the  upper  part  of  the  small  intestine.  Atresia  is  the  more 
common.  In  stenosis  the  child  may  live  weeks  or  even 
months ;  in  atresia  death  usually  takes  place  within  a  week 
after  birth. 

Meckel's  Diverticulum. — This  is  the  remains  of  the 
omphalomesenteric  duct  which  connects  the  umbilical  vesi- 
cle and  the  intestine  during  fetal  life.  When  it  persists  it  is 
usually  seen  as  a  blind  pouch  several  inches  long,  coming 
off  from  the  lower  part  of  the  ileum.  It  may  occur  in 
hernias.  There  may  be  a  fibrous  cord  from  it  ending  at  the 
umbilicus,  which  is  a  cause  of  intestinal  strangulation. 

Deformities  of  the  Rectum. — There  are  three  deformi- 
ties of  the  rectum.  It  may  end  in  a  blind  pouch  some  distance 
above  the  anus.  There  may  be  an  anus,  and  the  lower  part  may 
be  present,  but  separated  from  the  upper  by  a  membranous  sep- 
tum, or  there  may  be  a  complete  rectum  but  no  anus.  The 
last-named  is  easily  operated  upon  successfully.  The  second 
may  be  sometimes,  while  the  first  is  practically  always  fatal. 

CONGENITAL  ABSENCE  OF  THE  ABDOMINAL  MUSCLES. 

This  is  a  rare  condition  in  which  the  abdominal  muscles 
are  either  partially  or  entirely  absent.  The  abdomen  is 
enlarged  and  pendulous.  The  folds  of  the  intestines  and 
the  peristaltic  movements  are  plainly  visible.  On  palpation 
the  abdominal  organs  can  be  plainly  felt,  as  the  abdominal 
wall  consists  of  only  skin  and  connective  tissue.  In  cases 
where  the  muscles  are  only  partially  absent  the  bands  of 
muscle  fibers  can  usually  be  seen  and  felt.  In  rickets  the 
rectus  abdominalis  is  frequently  deficient.  Children  whose 
abdominal  muscles  are  defective  are  generally  constipated. 
Where  there  are  other  malformations,  or  an  absence  of  ab- 
dominal skin  as  well  as  muscles,  the  child  may  either  be 
born  dead  or  die  soon  after  birth. 


DISEASES  OF  THE  INTESTINES.  153 

Treatment. — In  the  more  severe  grades  the  abdomen 
should  be  supported  by  a  snugly  fitting  supporter.     A  flannel 


Fig.  42.— Congenital  absence  of  abdominal  muscles. 

bandage  may  be  all  that  is  required  where  the  muscles  are 
partially  present. 

CATARRHAL  JAUNDICE—  GASTRODUODENITIS. 

Definition. — A  catarrhal  inflammation  of  the  stomach 
and  upper  part  of  the  small  intestine  which  extends  into  the 
bile  duct. 

Btiology. — It  is  rare  under  two  years  of  age,  but  is  seen 
in  older  children.  It  may  come  on  without  apparent  cause 
or  it  may  complicate  any  of  the  infectious  diseases. 

Pathology.  —  Besides   the    catarrhal    condition   of  the 


154  DISEASES  OF  INFANTS  AND  CHILDREN. 

stomach  and  intestine  the  bile-duct  is  inflamed,  and  frequently 
there  is  a  plug  of  tenacious  mucus  filling  Vater's  diverticu- 
lum and  causing  an  obstructive  jaundice. 

Symptoms. — There  is  a  sudden  onset  with  pain  in  the 
right  hypochondrium,  vomiting,  and  slight  fever.  After 
several  days  jaundice  appears.  This  varies  in  intensity,  but 
is  generally  not  very  severe.  The  liver  is  usually  somewhat 
enlarged  and  tender,  the  urine  is  bile-stained,  the  stools  are 
white  and  with  a  foul  odor,  the  tongue  is  coated,  with  com- 
plete loss  of  appetite  and  great  lassitude.  Itching  of  the 
skin  and  slow  pulse  are  rare  under  seven  years  of  age. 
After  a  week  or  two  the  symptoms  pass  off  and  the  jaun- 
dice disappears  a  little  later. 

Diagnosis. — See  Diseases  of  the  Liver  for  symptoms  of 
the  other  diseases. 

Prognosis. — Good. 

Treatment. — Diet. — Give  little  or  no  starchy  food  or 
fats.  Give  a  moderate  amount  of  milk  peptonized  or  diluted 
with  a  carbonated  water  or  lime-water.  Give  fresh  green 
vegetables,  fruit,  and  rare  meat.  Diet  until  the  jaundice  has 
disappeared. 

Medicine. — Vichy  water  to  drink.  Calomel  at  the  outset. 
Phosphate  of  soda  in  hot  water  every  other  morning  or  every 
morning.  Treat  gastric  symptoms  like  acute  gastric  indi- 
gestion.    If  there  is  pain  use  counter-irritation. 

DIARRHEA, 

Diarrhea  is  a  term  used  to  designate  frequent  loose  move- 
ments of  the  bowel.  Diarrhea  is  most  common  in  hot  weather, 
especially  seen  in  frequency  and  severity  in  July  and  August. 
It  is  more  common  and  also  more  fatal  among  poor  children 
whose  surroundings  are  unhygienic,  where  there  are  filth, 
overcrowding,  and  lack  of  fresh  air.  The  weak  and  diseased 
suffer  more  than  the  healthy,  and  the  teething  child  more 
than  the  one  who  is  not  teething.  Four-fifths  of  the  cases 
are  under  two  years  of  age,  and  the  greatest  number  of  these 
between  twelve  and  eighteen  months.  The  mortality  corre- 
sponds with  the  frequency  of  attack.     One  of  the  greatest 


DISEASES  OF  THE  INTESTINES.  15S 

factors  in  causing  diarrhea  is  the  use  of  improper  or  impure 
food.  Spoilt  milk  is  the  most  common  cause.  Impure  water 
may  also  be  a  causal  factor.  Over  95  per  cent,  of  the  cases  of 
the  so-called  summer  diarrheas  occur  in  artificially  fed  babies. 

Diarrhea  may  be  classified  as  of  simple  and  infectious 
origin.  In  the  simple  forms  there  are  only  present  the 
normal  bacteriologic  flora  of  the  intestine.  In  the  infec- 
tious form  there  are  present  bacteria  not  normally  present  in 
the  intestine,  and  which,  we  may  assume,  are  causal  factors 
or  the  cause  of  pathologic  complications. 

The  simple  diarrheas,  according  to  Holt,  are  : 

1.  Mechanical. — From  indigestible  articles  taken  into 
the  intestine.  These  may  be  taken  as  food  or  otherwise. 
Green  fruit  is  the  most  common  example. 

2.  Medicinal. — From  laxative  drugs. 

3.  Reflex. — From  fright,  overheating,  or  chilling,  and 
the  like. 

4.  Blitninative. — As  the  diarrhea  of  uremia. 

The  first  causes  what  may  be  described  as  intestinal  indi- 
gestion. 

There  is  at  present  no  very  good  classification  of  the  infec- 
tious forms.  They  are  described  below  under  the  following 
headings  :  Acute  gastro-enteritis,  including  cholera  infantum, 
acute  ileocolitis  and  colitis,  chronic  ileocolitis,  and  amebic 
colitis. 

ACUTE  INTESTINAL  INDIGESTION. 

Etiology. — The  same  as  acute  gastric  indigestion,  which 
it  may  accompany.  It  is  frequently  seen,  however,  without 
any  gastric  involvement. 

Symptoms. — If  the  stomach  is  involved  as  well  there 
will  be  symptoms  of  gastric  indigestion.  There  are  pain 
and  diarrhea.  There  may  or  may  not  be  distention  of  the 
abdomen.  There  are  present  prostration  and  fever  ranging 
from  100°  to  105°  F.  or  more. 

The  stools  are  at  first  the  normal  feces,  but  loose  and  fre- 
quent. Later  there  are  thin  movements  which  are  greenish 
or  brownish  in  color,  which  may  have  a  very  foul  odor  and 
which  contain  particles  of  undigested  food,  fat,  the  curd  of 


156  DISEASES  OF  INFANTS  AND  CHILDREN. 

the  milk,  or  other  things  if  they  have  been  taken.     After  a 
day  or  two  there  may  be  mucus  in  large  quantity. 

Diagnosis. — Diagnosis  from  the  infectious  forms  is  made 
by  its  comparative  mildness,  the  infrequency  of  vomiting, 
and  short  duration.  At  the  outset  there  is  absolutely  no 
way  to  tell  what  form  of  diarrhea  one  has  to  deal  with. 

Prognosis. — Good  in  strong  children  where  the  attack 
is  properly  treated  at  the  time  and  subsequently.  May  cause 
death  in  weak  infants  and  predisposes  to  other  bowel  disease. 

Treatment. — Clean  out  the  stomach  and  bowel.  Wash 
out  if  necessary.  Give  calomel  (10  y1^-  gr.  doses)  if  there  is 
vomiting,  or  a  full  dose  of  castor  oil  if  there  is  not.  After 
the  bowel  has  been  thoroughly  emptied  (but  never  until  then) 
small  doses  of  paregoric  or  Dover's  powder  may  be  given  if 
there  are  very  frequent  stools  or  very  much  pain.  Opium  should 
always  be  used  with  great  caution.  After  the  bowels  are  emptied 
bismuth  may  be  given  in  combination  with  chalk  mixture. 
Subcarbonate  (1-2  gr.)  or  subnitrate  (5-10  gr.)  every  two  or 
three  hours.     Essence  of  pepsin  may  be  added  if  desired. 

Withhold  all  food  for  the  first  twenty-four  hours,  except 
a  little  albumin-water.  This  is  best  given  in  small  doses  at 
not  too  great  intervals.  Plain  boiled  water  may  be  used 
instead.  Very  weak  tea  to  which  a  little  red  wine  has  been 
added  may  be  given  if  the  child  is  weak.  On  the  second 
day  the  albumin-  or  barley-water  may  be  given  with  the 
addition  of  weak  strained  broth,  and  on  the  third  day  malted 
milk  may  be  added  to  the  list.  After  four  or  five  days 
cows''  milk  diluted  and  boiled  or  peptonized  may  be  tried. 
It  is  best  mixed  with  a  farinaceous  gruel  or  with  malted  milk 
to  start  with.  It  may  be  given  every  other  feeding  for  a  day 
or  two  if  it  agrees,  and  the  former  feeding  gradually  resumed. 

In  nursing  infants  withhold  the  breast  twenty-four  hours 
and  feed  as  above.  After  that  the  breast  may  be  given  once 
for  a  few  minutes  and  the  feeding  pieced  out  with  albumin- 
or  barley-water.  If  it  agrees  the  breast  may  be  given  for 
three  or  four  feedings,  every  other  feeding  followed  by  albu- 
min- or  barley-water.  On  the  following  day  the  breast  may 
be  given  at  each  feeding.  The  time  of  nursing  should  be 
increased  gradually  until  the  child  is  back  on  its  old  schedule. 


DISEASES  OF  THE  INTESTINES.  157 

THE  INFECTIOUS  DIARRHEAL  DISEASES.1 

The  infectious  diarrheal  diseases  are  not  very  thoroughly 
understood  as  yet,  and  there  are,  in  consequence,  numerous 
classifications  and  a  diverse  nomenclature.  There  may  be 
severe  symptoms,  with  few  or  no  lesions  in  the  bowel,  or 
there  may  be  extensive  lesions.  The  disease  may  run  a  rapid 
course  or  a  prolonged  one.  Toxic  symptoms  may  be  pro- 
nounced or  wanting.  The  differences  seem  to  depend  on  the 
virulence  of  the  infection  and  the  condition  and  resistance 
of  the  child.  In  the  very  acute  cases  the  symptoms  are 
chiefly  of  a  toxic  nature,  from  the  absorption  of  the  poisons 
produced  by  the  bacteria  in  the  bowels. 

There  are  practically  always  some  pathologic  lesions,  usually 
of  an  inflammatory  type.  In  the  more  prolonged  cases  they 
are  liable  to  be  more  severe  and  may  result  in  ulceration  of 
the  intestine. 

Certain  fairly  well-marked  clinical  forms  may  be  described, 
but  it  is  sometimes  difficult  to  draw  hard-and-fast  dividing 
lines. 

ACUTE  GASTRO-ENTERITIS.2 

(Summer  Diarrhea;  Summer  Complaint;  Acute  Intestinal  Intoxication; 

Cholera  Infantum,  Etc.) 

Definition. — An  acute  infectious  diarrhea  occurring  most 
frequently  in  summer. 

Etiology. — While  it  is  seen  the  whole  year  the  greatest 
number  of  cases  occur  in  hot  weather.  Nearly  all  the  cases 
and  nearly  all  the  deaths  are  in  bottle-fed  babies.  It  is  most 
prevalent  among  the  poor  and  overcrowded.  It  is  most  fre- 
quent in  children  under  two  years  of  age. 

The  bacteria  findings  are  various.  It  appears  that  many 
different  organisms  may  under  certain  conditions  multiply  in 
the  intestinal  tract  and  cause  diarrhea.  The  Shiga-Flexner 
bacillus  (Bacillus  dysentericus)  has  been  found  in  the  stools 

i  Studies  of  the  Diarrheal  Diseases  of  Infancy,  from  the  Eockefeller  Insti- 
tute for  Medical  Research.  , 

2  Maurice  Ostheimer,  "  Diarrhea,  Summer,  Preventfon  of,  Journal  of 
the  American  Medical  Association,  August  26,  1905,  p.  595. 


,158  DISEASES  OF  INFANTS  AND  CHILDREN. 

in  some  instances,  but  the  majority  of  the  cases  are  not 
caused  by  it.  Pus  germs  are  found  in  some  cases,  usually 
in  the  severer  forms  described  as  cholera  infantum. 

Pathology. — The  bowel  contains  mucus  and  fecal  mate- 
rial similar  to  the  stools.  There  may  be  some  congestion  of 
the  mucous  membrane  and  some  swelling  of  the  lymph- 
nodes.  There  are  degenerations  in  the  epithelium.  There 
may  be  an  associated  nephritis,  bronchopneumonia,  and  de- 
generations in  the  liver  cells. 

Symptoms. — The  onset  may  be  gradual,  with  but  little 
fever  and  symptoms  of  intestinal  indigestion,  or  it  may  be 


Fig.  43. — Acute  intestinal  intoxication.  Note  the  facial  expression  and  corneal  ulcer. 

sudden  with  high  fever.  In  the  first  class  the  child  is  not 
quite  well,  has  loose  stools,  usually  undigested  and  discol- 
ored. Recovery  may  be  prompt  or  the  disease  may  assume 
the.  character  of  the  severe  form. 

In  the  severer  form  fever  and  prostration  exist ;  the  child 
is  at  first  restless  and  nervous,  but  later  on  may  become  listless 
and  semicomatose.  There  may  be  delirium,  convulsions,  or 
coma.  There  is  vomiting,  frequently  continuous,  and  of 
everything  that  the  child  swallows.  The  stools  are  frequent. 
First  the  natural  intestinal  contents  are  passed,  then  mucus 
mixed  with  fecal  matter,  usually  greenish  or  brownish  in 
color.  There  may  be  blood  or  pus.  The  loss  of  weight  is 
great  and  the  child  becomes  weak,  pale,  and  a  few  days  may 
so  change  a  child's  appearance  that  it  is  unrecognizable.  The 
child  may  recover,  die,  or  tbe  disease  may  become  chronic 


DISEASES  OF  THE  INTESTINES.  159 

and  change  into  an  ileocolitis.    Relapses  are  frequent,  usually 
due  to  errors  in  diet. 

Cholera  Infantum. — This  is  a  form  of  diarrhea  char- 
acterized by  marked  toxic  symptoms,  high  fever,  severe 
vomiting,  profuse  discharge  of  copious  thin  stools,  great  loss 
of  weight,  and  usually  death.  A  small  percentage  recover. 
The  symptoms  resemble  those  seen  in  Asiatic  cholera ;  hence 
the  name. 

Diagnosis. — At  the  outset  it  is  impossible  to  tell  whether 
a  diarrhea  is  of  the  severe  type  or  merely  an  intestinal  indi- 
gestion. The  latter  usually  responds  to  treatment,  and  when 
the  bowel  is  cleansed  the  symptoms  subside.  A  continuance 
of  the  symptoms  means  an  infectious  diarrhea. 

Acute  diseases,  such  as  pneumonia  or  scarlet  fever,  may 
start  in  with  a  diarrhea.  Meningeal  symptoms  may  be 
marked  and  the  case  mistaken  for  a  meningitis.  A  sunken 
fontanel  belongs  to  diarrhea  rather  than  meningitis.  Lum- 
bar puncture  may  be  resorted  to. 

Prognosis. — In  good  surroundings  with  proper  treat- 
ment, fair  ;  in  weak  children  and  in  poor  surroundings  or  with 
improper  care,  bad. 

Prophylaxis. — Fresh  air  ;  cleanliness  ;  pure  food  ;  more 
water  and  less  food  during  the  hot  weather  ;  disinfection  of 
the  stools  and  things  which  have  been  in  contact  with  the  case. 

Treatment. — If  in  city  send  to  country  where  it  is  pos- 
sible. Keep  the  child  in  the  fresh  air.  Keep  the  child 
clean.  Cold  sponging  or  bathing  should  be  used  to  reduce 
fever.     An  ice-bag  may  be  used  on  the  head. 

Dietetic  Management.1 — Breast-fed  Infants. — In  Winter. — 
Lengthen  nursing  periods  to  six  hours.  In  the  meantime 
give  boiled  water,  whey,  albumin-,  rice-  or  barley-water. 
After  a  day  or  two,  if  all  goes  well,  resume  nursings  on  the 
regular  schedule. 

In  Summer. — Withhold  all  milk  for  twenty-four  hours  and 
give  above-mentioned  articles  every  three  or  four  hours. 
Plain  boiled  water  is  perhaps  best,  allowing  the  bowel  a  per- 
fect rest.  This  alone  often  cures  the  diarrhea  promptly. 
Whisky  and  water,  or  one  of  the  liquid  beef  preparations,  may 
1  See  Diet  in  Health  and  Disease,  by  Friedenwald  and  Rulirali. 


160  DISEASES  OF  INFANTS  AND   CHILDREN. 

be  given  in  water  if  the  child  is  weak.  If  the  child  is  better  on 
the  second  day  it  may  be  allowed  to  nurse  a  few  minutes.  If  this 
does  not  cause  an  increase  in  the  diarrhea  nursing  may  be  grad- 
ually resumed.  The  mother's  breasts  should  always  be  pumped 
out  at  the  nursing  intervals  to  maintain  a  free  flow  of  milk. 

Bottle-fed  Babies. — Withhold  all  fresh  milk  until  complete 
recovery.  During  the  first  twenty-four  hours  nothing  but 
boiled  water.  Whisky  and  water,  or  liquid  beef  preparations 
and  water,  may  be  used  if  baby  is  very  weak.  On  the  second 
day  albumin-,  barley-,  or  rice-water.  On  the  third  or  fourth 
day  try  malted  milk.  If  this  is  well  borne,  milk  and  barley 
or  rice-water,  equal  parts,  well  boiled,  may  be  tried.  The 
return  to  fresh  milk  should  be  gradually  made.  Whey  is  useful. 

If  there  is  vomiting  withhold  food  and  wash  out  the  stom- 
ach. Equal  parts  of  lime  water  and  cinnamon  water  in  tea- 
spoonful  doses  is  useful  to  stop  vomiting.  Tiny  bits  of  ice 
may  be  given  to  allay  thirst.  Lime-water  with  the  food  in 
20  per  cent,  to  30  per  cent,  proportion  is  useful  if  gastric 
symptoms  persist. 

If  tbe  fluids  are  abstracted  from  the  body  so  that  collapse 
threatens  give  several  ounces  of  normal  salt  solution  under 
the  skin. 

Other  Treatment. — Wash  out  the  stomach  and  bowel.  If 
seen  early  administer  calomel  (-^  gr.  every  half  hour  for  ten 
doses)  if  there  is  vomiting,  or  castor  oil  if  there  is  not. 
Salines  may  be  used.  After  cleansing  the  bowel  give  one 
of  the  following  :  Bismuth  subnitrate  (5—10  gr.  every  two 
hours) ;  bismuth  subcarbonate  (1-5  gr.)  ;  bismuth  subga7- 
late  (1—5  gr.).  Resorcin,  bismuth  salicylate,  salicylate  of 
soda,  salol,  and  beta-naphthol  bismuth  may  be  used.  Bis- 
muth subnitrate  in  chalk  mixture  is  about  the  best.  Avoid 
too  much  drugging.  Opium  should  be  used  with  great  cau- 
tion to  diminish  the  number  of  stools,  relieve  pain  and  pro- 
duce sleep.  It  should  never  be  used  until  the  bowel  has 
been  thoroughly  cleansed,  as  it  may  cause  the  retention  of 
very  toxic  fecal  material.  Paregoric  and  Dover's  powder  are 
most  frequently  used. 

Strychnia  and  whisky  may  be  administered  if  stimulants 
are  needed.     Use  small  doses  well  diluted. 


DISEASES  OF  THE  INTESTINES.  161 

ACUTE  ILEOCOLITIS. 

Enterocolitis;  Enteritis;  Dysentery;  Inflammation  of  the  Bowels. 

Definition. — An  inflammation  of  the  large  and  small 
bowel  characterized  by  frequent  bowel  movements,  tenesmus 
and  marked  constitutional  disturbance.  Three  forms  may 
be  described  :  catarrhal,  ulcerative  and  membranous. 

It  is  often  impossible  to  distinguish  cases  of  acute  gastro- 
enteritis from  cases  of  ileocolitis.  The  classification  is  by  no 
means  perfect. 

Etiology. — The  causes  are  the  same  as  for  acute  gastro- 
enteritis. The  Shiga-Flexner  bacillus  can  be  demonstrated 
in  many  cases.  There  may  be  pus  germs  present  as  well. 
Many  cases  follow  the  milder  forms  of  diarrhea. 

Pathology. — The  lymph  follicles  are  enlarged  and  ulcer- 
ated in  most  cases.  In  others  there  is  a  simple  catarrhal 
inflammation  and  there  may  be  simple  ulcerations  of  the 
mucous  membrane.  In  other  cases  there  is  a  membranous 
inflammation.  The  lesions  are  for  the  most  part  in  the  colon 
and  lower  part  of  the  ileum.  The  most  frequent  compli- 
cating lesions  are  bronchopneumonia  and  nephritis. 

Symptoms. — Catarrhal  Form. — There  is  usually  a  sud- 
den onset,  vomiting  and  diarrhea  ;  the  stools  contain  blood 
and  mucus.  There  is  great  pain  wirh  tenesmus.  The  stools 
are  very  frequent.  There  are  fever  and  toxic  symptoms  with 
more  or  less  prostration.  In  mild  cases  the  acute  symptoms 
last  about  a  week,  but  there  is  a  great  tendency  to  become 
chronic.  In  severe  cases  the  acute  symptoms  may  last 
weeks. 

Ulcerative  Form. — This  is  usually  secondary  to  a  gastro- 
enteritis. There  is  not  so  much  temperature  as  in  the  pre- 
ceding, and  the  stools  are  not  as  frequent.  Blood  is  seen 
sometimes.  There  is  progressive  emaciation  with  great  weak- 
ness.    The  diagnosis  is  made  from  the  general  history. 

Membranous   Form. — This   is   always   severe.     There  is  a 

sudden  onset  with  vomiting  and  high  fever,  as  in  the  catarrhal 

form,  but  if  anvthin^  more  intense.     There  mav  be  marked 

nervous  svmptoms.     The  diagnosis  is  made  on  the  presence 
11 


162  DISEASES  OF  INFANTS  AND  CHILDREN 

of  pieces  of  membrane  in  stools  otherwise  like  those  seen  in 
catarrhal  ileocolitis. 

Diagnosis. — From  typhoid  by  the  Widal  reaction  and  the 
slower  invasion  of  typhoid.  From  intussusception  by  the 
constipation  following  the  onset  and  the  symptoms  of  obstruc- 
tion. The  membranous  form  is  sometimes  mistaken  for 
meningitis  if  the  cerebral  symptoms  are  marked.  Diarrhea 
is  rare  in  meningitis. 

Prognosis. — Bad  in  all  cases.  Many  of  the  catarrhal 
forms  recover,  but  relapse  is  frequent.  The  ulcerative  form 
is  usually  fatal,  but  sometimes  partial  recovery  takes  place, 
and  the  child  may  die  of  some  intercurrent  affection.  The 
membranous  form  is  usually,  though  not  always,  fatal.  In  the 
poor,  in  previously  ill  children,  and  in  hot  weather  the  out- 
look is  especially  bad. 

Treatment. ^Very  much  the  same  as  in  acute  gastro- 
enteritis. Fresh  air  or  a  change  of  air  is  important.  Opium 
is  needed  for  the  pain  and  frequent  stools.  Irrigation  of  the 
bowel  is  also  useful.  Flush  the  bowel  with  normal  salt  solu- 
tion and  then  use  fluid  extract  of  witch-hazel  (1  dr.  to  1 
pint)  or  some  other  astringent.  Nitrate  of  silver  is  sometimes 
useful. 

CHRONIC  ILEOCOLITIS. 

(Chronic  Dysentery.) 

Definition. — A  chronic  inflammation,  often  with  ulcera- 
tion of  the  ileum  and  colon,  characterized  clinically  by  pain 
and  chronic  diarrhea. 

Etiology. — It  almost  always  follows  the  acute  form  of 
the  disease. 

Pathology. — There  is  a  catarrhal  form  in  which  there  are 
present  an  increased  amount  of  mucus,  pigmentation  of  the 
mucous  membrane,  proliferation  of  the  lymphoid  tissue  of 
the  intestines  and  of  the  lymph-nodes  connected  with  it. 
There  is  also  an  ulcerative  form  in  which,  in  addition  to  the 
above,  there  are  ulcerations.  These  may  be  follicular  or  of  a 
broad  flat  type.  Cystic  degeneration  of  the  intestine  is  a 
rare  lesion.     The  liver  is  fatty,  nephritis  is  not  uncommon, 


DISEASES  OF  ?HE  INTESTINES.  163 

and  lesions  in  the  lungs,  either  tuberculosis  or  bronchopneu- 
monia, may  be  present. 

Symptoms. — Emaciation  and  weakness,  little  or  no 
fever.  Numerous  thin,  brownish  or  greenish  stools  contain- 
ing undigested  food  and  pus  and  occasionally  blood.  Colic 
and  pain  in  the  abdomen  may  be  present.  The  abdomen  is 
usually  distended  with  gas.  There  are  frequently  ulcerations 
about  the  mouth  and  anus.  Nervous  symptoms  may  be 
marked. 

Diagnosis. — It  may  be  impossible  to  tell  the  disease 
from  tuberculosis,  as  tuberculosis  is  not  uncommon  as  a  com- 
plication. Fever  is  absent  or  slight,  while  it  is  nearly  always 
present,  though  irregular,  in  tuberculosis. 

Prognosis. — Cases  last  from  weeks  to  a  year.  The 
longer  the  preceding  acute  stage  has  lasted  the  worse  the 
prognosis.  Death  frequently  takes  place  within  several 
months.     Remarkable  recoveries  may  take  place. 

Treatment. — Good  care  and  careful  diet  is  the  most 
important  part.  A  change  to  mountains  or  seashore  may 
work  wonders.  Foods  leaving  but  little  residue  should  be 
used.  Predigested  milk  and  beef  preparations,  white  of  egg, 
rare  or  raw  scraped  beef,  malted  foods,  and  alcohol  are  the 
most  useful.  Washing  out  the  bowel  is  of  value  ;  a  cleans- 
ing enema  of  warm  salt  solution,  followed  by  a  small  injec- 
tion of  fluid  extract  of  witch-hazel  or  some  other  mild 
astringent,  is  best.  Opium  may  be  used  to  lessen  the  num- 
ber of  stools  if  excessive.  Drugs  may  be  given  for  flatulence, 
pain,  or  other  symptoms. 

AMYLOID  DEGENERATION  OF  THE  INTESTINES. 

This  is  sometimes  seen  in  older  children.  The  causes  are 
the  same  as  for  amyloid  changes  in  other  organs.  There  are 
anemia  and  cachexia,  enlargement  of  liver  and  spleen,  a 
cause  of  amvloid  disease,  and  in  some  cases  there  mav  be  a 
diarrhea.  In  many  instances  of  the  disease  diagnosis  is  not 
determined  until  after  death.  The  treatment  is  to  remove 
the  cause  where  possible. 


164  DISEASES  OF  INFANTS  AND  CHILDREN. 

AMEBIC  COLITIS.1 

Definition. — A  form  of  colitis  associated  with  the  pres- 
ence of  the  ameba  coli  in  the  stools  and  lesions. 

Etiology. — This  is  rare  in  children,  but  is  perhaps  more 
frequent  than  is  generally  supposed.  The  ameba  coli  is  re- 
garded as  the  cause  of  the  disease.  The  youngest  case 
reported  was  in  a  child  about  two  years  old. 

Pathology. — This  is  the  same  as  in  adults.     There  are 


Fig.  44.— Ameba  coli. 

ulcerations  in  the  colon,  which  undermine  the  mucous  mem- 
brane. 

Symptoms. — The  disease  is  usually  subacute  or  chronic, 
although  acute  cases  may  be  seen.  The  onset  is  frequently 
abrupt,  with  fever  and  diarrhea.  The  symptoms  frequently 
disappear  to  recur  after  a  short  interval.  During  the  ex- 
acerbations there  is  diarrhea  accompanied  with  pain  and 
tenesmus  and  some  fever. 

Diagnosis. — This  is  made  on  finding  the  ameba  in  the 
stools,  or,  better  still,  from  scrapings  from  the  ulcers. 

Prognosis. — The  disease  lasts  months  or  years  and  fre- 
quently ends  fatally  from  exhaustion,  hemorrhage,  or  liver 
abscess. 

Treatment. — General  supporting  treatment,  together 
with  irrigation  of  the  bowel  with  normal  salt  solution,  fol- 
lowed by  quinin  solution  from  1  :  5000  to  1  :  1000. 

CHRONIC  INTESTINAL  INDIGESTION. 

Definition. — A  condition  in  which  food  in  the  intestine 
is  imperfectly  digested. 

1  Amberg,  Bulletin  Johns  Hopkins  Hospital,  Dec,  190L 


DISEASES  OF  THE  INTESTINES.  165 

Btiology. — It  may  follow  acute  attacks,  improper  feed- 
ing, or  general  debility. 

Pathology. — There  is  usually  an  associated  catarrh  of 
the  intestinal  mucous  membrane. 

Symptoms. — In  infants  gastric  indigestion  is  frequently 
associated.  Malnutrition  is  the  most  prominent  symptom. 
There  may  be  diarrhea  or  constipation.  Undigested  food  is 
seen  in  the  stools.  The  stools  are  frequently  discolored  (see 
Infant  Stools,  p.  106). 

Symptoms  in  Older  Children. — These  children  are  emaciated, 
nervous,  and  capricious.  There  is  flatulence  and  often  a 
distended  abdomen.  There  may  be  chronic  diarrhea,  or  a 
diarrhea  alternating  with  constipation,  or  more  rarely  consti- 
pation. The  stools  are,  as  a  rule,  very  offensive  and  contain 
a  great  deal  of  mucus.  Fever  and  nervous  symptoms  may 
be  present  at  times.  The  symptoms  are  very  numerous  and 
varied. 

Diagnosis. — This  usually  presents  no  difficulty. 

Prognosis. — This  is  good  if  seen  early  and  the  child  can 
be  properly  cared  for  and  dieted. 

Treatment. — This  is  mainly  hygienic  and  dietetic.  In- 
fants should  be  cared  for  as  suggested  for  malnutrition,  and 
the  food  regulated  according  to  general  principles.  Consid- 
erable experience  is  often  required  to  adapt  the  food  to  the 
infant's  digestion. 

In  older  children  the  diet  should  be  milk,  meat  juice,  and 
rare  meat  and  egg  albumin.  Later  malted  food,  zwieback, 
orange  juice,  and  other  articles  of  diet  mav  be  cautiously 
added. 


INTESTINAL  COLIC. 

Definition. — Severe  paroxysmal  pain  in  the  intestines. 

Etiology. — Flatulence  from  indigestion,  especially  in 
nursing  infants ;  in  artificially  fed  babies,  excesses  either  in 
proteins,  sugar  or  fat ;  indigestible  articles  of  food ;  inflam- 
mation of  the  abdominal  viscera  and  reflexly  from  cold  feet 
and  exposure  to  cold. 

Symptoms. — Crying,  evident  discomfort  and  pain,  and 


166  DISEASES  OF  INFANTS  AND  CHILDREN. 

a  hard  tympanitic  abdomen.  There  may  be  cyanosis  of  feet 
and  hands.     Relief  frequently  follows  the  expulsion  of  gas. 

Diagnosis. — Exclude  peritonitis,  appendicitis  and  in- 
flammatory conditions. 

Prognosis. — Good  as  regards  attack.  The  disease  may 
recur  frequently. 

Treatment. — An  enema  of  warm  water  or  of  water  and 
glycerin  to  expel  the  gas.  Heat  or  counterirritation  to 
abdomen  by  hot-water  bottle  or  spice  bag.  Internally,  aro- 
matics,  and  in  very  severe  cases  doses  of  codein  or  pare- 
goric.    In  the  intervals  treat  the  indigestion. 

CHRONIC  CONSTIPATION.1 

Definition. — A  condition  where  the  stools  are  less  fre- 
quent or  harder  than  normal. 

Etiology. — Constipation  may  be  due  to  a  large  number 
of  causes.  Improper  diet  is  one  of  the  most  frequent.  A 
diet  which  gives  too  little  volume  of  refuse,  or  one  lacking  in 
fat  in  younger  children,  or  in  fruits  and  vegetables  in  older 
children,  may  be  the  cause.  Atony  of  the  intestines  is  also  a 
frequent  cause.  Insufficient  secretion  from  the  intestinal 
glands  or  the  liver  may  also  be  a  cause.  Pain  on  defeca- 
tion, caused  by  fissures  of  the  anus  and  the  like,  may  result 
in  infrequent  stools. 

Symptoms. — Discomfort,  pain  in  the  abdomen,  and 
straining  at  stool.  In  some  cases  there  are  no  apparent  ill 
effects,  whereas  in  others  there  may  be  toxic  symptoms, 
headache,  languor,  and  disturbed  sleep. 

Diagnosis. — The  cause  should  be  sought.  The  anus  and 
rectum  should  be  examined. 

Prognosis. — Often  persists  for  a  long  time. 

Treatment. — Regular  habits  of  stool.  Regulation  of 
the  diet.  In  infants  see  that  they  get  sufficient  fat  and  pro- 
tein. Well-cooked  and  sweetened  oatmeal  gruel  is  useful. 
Orange  juice,  baked  apples,  or  prune  juice  taken  on  an  empty 
stomach  is  of  service.     Olive  oil,  the  malted  foods,  or  malt 

1  Pritchard,  "Constipation  in  Infants,"  The  Practitioner,  May,  1910,  p.  583. 
Poynton,  "  Constipation  in  Childhood,"  The  Practitioner,  May,  1910,  p.  567. 


DISEASES  OF  THE  INTESTINES.  167 

extracts  are  also  useful.  In  older  children  fresh  fruits,  vege- 
tables, and  oatmeal  porridge  are  of  value.  Graham  bread, 
dates,  figs,  and  prunes  may  be  used.  Massage  of  the  abdo- 
men is  of  some  value.  A  glass  of  water  taken  immediately 
on  rising  is  also  advisable. 

Enemata  should  be  used  to  empty  the  bowel  in  case  of  need. 

Suppositories,  either  plain  or  gluten,  or  containing  mix 
vomica,  belladonna,  or  hyoscyamus,  may  be  tried. 

From  one  to  four  teaspoonfuls  of  pure  liquid  petrolatum 
may  be  given  at  bedtime  in  obstinate  cases. 

Of  the  drugs,  castor  oil,  calomel,  and  the  salines  should 
be  used  only  when  it  is  desired  to  empty  the  bowels  quickly, 
never  as  a  routine  ;  mix  vomica,  belladonna,  hyoscyamus,  and 
cascara  are  the  best  for  chronic  constipation,  and  are  usually 
given  in  combination.  The  aromatic  syrup  of  rhubarb  is 
frequently  used.     Phosphate  of  soda  is  useful  in  some  cases. 

INTUSSUSCEPTION*1 

Definition. — The  invagination  of  one  piece  of  gut  into 
another  is  called  intussusception.  Intestinal  obstruction  re- 
sults. The  commonest  form  is  that  occurring  at  the  ileocecal 
valve  (ileocecal),  but  intussusception  of  the  small  intestine 
(enteric)  or  colon  (colic)  may  occur. 

Postmortem  intussusception  is  a  frequent  autopsy  find- 
ing. It  occurs  just  before  or  after  death  and  causes  neither 
local  reaction  nor  clinical  symptoms.  It  is  of  no  import- 
ance. 

Etiology. — Intussusception  is  more  common  in  boys 
than  girls,  and  the  majority  of  cases  occur  before  the  third 
year,  most  frequently  between  the  sixth  and  ninth  month. 
It  is  caused  by  irregular  intestinal  contraction.  This  is 
sometimes  produced  by  injury,  but  generally  no  exciting 
cause  can  be  determined. 

Pathology. — Congestion  and  swelling  of  the  gut  follow, 

rendering  reduction  difficult  or  impossible.     Gangrene  may 

follow  unreduced  intussusception.      The  portion  of  the  gut 

1  Snow,  Archives  of  Pediatrics,  vol.  xxi.,  p.  494.  I.  H.  Hess,  "Intussus- 
ception in  Infancy  and  Childhood,"  Archives  of  Pediatrics,  September,  1905, 
p.  655.  Dunbar,  "  Acute  Intussusception,"  Scottish  Medical  and  Surgical 
Journal,  August,  1906. 


168  DISEASES  OF  INFANTS  AND  CHILDREN. 

sloughed  may  be  passed  through  the  rectum.  In  chronic 
intussusception  adhesions  take  place,  but  gangrene  is  less 
common. 

Symptoms. — The  onset  is  sudden,  with  pain  and  vom- 
iting. The  pain  recurs  in  paroxysms ;  the  vomiting  con- 
tinues and  may  become  fecal.  There  are  one  or  two  loose 
stools,  after  which  only  blood  and  bloody  mucus  are  passed. 
The  abdomen  is  relaxed,  and  a  tumor  is  felt  either  in  the 
right  iliac  fossa  or  through  the  rectum.  There  is  marked 
shock.  If  not  reduced  the  vomiting  continues,  tympanites 
occurs,  and  later  on  fever.  There  may  be  symptoms  of  peri- 
tonitis. A  rapid  rise  in  temperature  usually  means  death 
within  twenty-four  hours.  Occasionally  there  may  be  sub- 
acute or  chronic  cases  with  less  intense  symptoms. 

Diagnosis. — The  symptoms  are  characteristic.  Make 
careful  abdominal  and  rectal  examinations  in  all  suspicious 
cases.     Do  not  mistake  ileocolitis. 

Prognosis. — This  is  always  bad.  Death  usually  takes 
place  between  the  third  and  the  fifth  day.  With  prompt 
diagnosis  and  treatment  the  outlook  is  somewhat  better  than 
formerly.  Recurrences  may  take  place,  usually  within 
twenty-four  hours  after  reduction. 

Treatment. — Anesthetize  and  either  inflate  with  air  or 
inject  salt  solution.  Rumbling,  uniform  filling  of  the  colon, 
and  sometimes  the  passing  of  feces  determine  if  reduction 
has  occurred.  The  disappearance  of  the  tumor  is  important. 
If  doubt  exists  or  the  symptoms  return  perform  a  laparotomy. 
Act  promptly ;  delay  means  death.  In  using  injections  do 
not  raise  the  syringe  over  three  feet  above  the  patient's 
body  for  fear  of  rupturing  the  bowel.  After  operation  keep 
quiet,  give  opium,  very  light  diet,  and  avoid  cathartics. 

APPENDICITIS-1 

This  is  rare  in  infants.     More  frequent  in  boys  than  girls. 

Foreign  bodies  are  an  occasional  cause,  digestive  disturbances 

1  Kelly  and  Hurdon,  The  Vermiform  Appendix,  p.  450.     Vincent,  "  Acute 
'  Appendicitis  in  Children,"  Boston  Med,  and  Surg.  Jour.,  Sept.  24, 1908,  p.  427. 


DISEASES  OF  THE  INTESTINES.  169 

especially  j  constipation  may  precede  it  in  some  cases;  in 
most  there  is  do  apparent  cause. 

Catarrhal,  suppurative,  gangrenous,  and  chronic  forms 
have  been  described  in  infant-. 

Catarrhal  Appendicitis. — Rarely  diagnosed  as  such.  The 
appendix  is  thickened.  There  is  pain  with  tenderness  over 
the  abdomen.  This  may  be  extreme,  and  is  located  midway 
1  >et ween  the  umbilicus  and  the  right  iliac  spine.  There  may 
be  vomiting  and  some  fever.  A  tumor  can  sometimes  be 
felt  in  the  right  iliac  fossa.  The  attack  passes  off  in  a  few 
days  or  a  week  or  passes  into  one  of  the  severer  forms. 
Entire  recovery  may  take  place  or  a  chronic  form  may 
follow.     Recurrences  are  frequent. 

Suppurative  Appendicitis. — Onset  as  above.  It  may  end 
in  any  of  the  following  : 

Localized  Peritonitis. — The  acute  symptoms  last  a  week 
or  two.  There  is  a  diffuse  hardness  in  the  right  iliac  fossa, 
which  becomes  more  definite  and  then  gradually  disappear-. 

Abscess. — A  tumor  mass  can  easily  be  made  out.  There 
are  fever,  pain,  and  tenderness.  Pus  is  present  early.  Sub- 
sidence sometimes  takes  place  or  it  may  rupture  into  the 
bowel.     Rupture  into  the  peritoneum  causes  peritonitis. 

General  peritonitis,  which  may  also  be  caused  by  perfora- 
tion in  gangrenous  appendicitis. 

Gangrenous  Appendicitis. — Onset  as  in  catarrhal  form. 
May  become  rapidly  worse  at  any  time  with  sudden  pain, 
vomiting,  and  symptoms  of  shock.  Peritonitis  follows  with 
tympanites  and  great  tenderness.  There  may  be  a  lull  in 
the  symptoms,  but  death  takes  place  in  nearly  all  cases  in 
from  one  to  five  days. 

Prognosis. — The  prognosis  of  appendicitis  is  worse  in 
children  under  six  or  seven  than  in  the  adult.  Over  seven 
it  is  somewhat  better.  Much  depends  on  good  judgment  and 
skilful  treatment. 

Diagnosis.1 — Sudden  onset,  pain  in  the  abdomen,  vomit- 
ing, tenderness,  rigidity,  and  sometimes  tumor  in  the  right  iliac 
fossa,  are  the  principal  points.     Colic  is  of  shorter  duration  ; 

1  J.  N.  Hess,  "  Appendicitis  in  Children,  Diagnosis  of,"  Archives  of  Pedi- 
atric.?, May,  1905,  p.  329. 


170  DISEASES  OF  INFANTS  AND  CHILDREN. 

there  is  no  fever  and  no  localized  tenderness.  Intussusception 
is  rare  after  two  years  of  age  ;  the  sudden  onset,  with  a  tumor 
at  the  start  and  the  more  intense  symptoms,  paroxysmal 
pain  and  the  bowel  obstruction,  usually  suffice.  Acute  in- 
digestion cannot  be  differentiated  at  the  start,  but  it  is  re- 
lieved by  treatment.  Pneumonia  or  pleurisy  may  cause 
extreme  abdominal  tenderness.  Psoas  abscess  generally 
presents  no  difficulties.  Blood-counts  are  of  some  value  in 
the  hands  of  an  expert,  but  do  not  draw  too  definite  conclu- 
sions from  blood-counts.  Leukocytosis  over  20,000  may 
mean  abscess  and  may  be  helpful  in  differentiating  appen- 
dicitis from  other  intestinal  disturbances.  Rapidly  increasing 
leukocytosis  is  of  more  value.  Leukocytosis  may  occur  in  any 
severe  intestinal  disorder,  and  is  present  in  pneumonia. 

Treatment. — Rest.  If  very  restless  use  a  long  side 
splint  or  a  light  plaster  cast.  Watch  carefully.  Opiate  for 
pain.  Give  castor  oil  at  the  outset  and  then  wash  out  the 
colon  daily,  and  the  stomach,  too,  if  there  is  vomiting  and  it 
is  possible  to  do  it  without  too  much  excitement  on  the  part 
of  the  child.  Avoid  cathartics.  Operate  at  once  in  localized 
abscess  and  the  gangrenous  form.  In  other  forms,  if  seen 
during  the -first  forty -eight  hours,  operation  may  be  done  at 
once ;  if  seen  later  wait  until  the  process  becomes  localized 
and  walled  off  by  peritoneal  adhesions.  Operation  between 
the  attacks  may  be  considered  in  the  catarrhal  form. 

DILATATION  AND  HYPERTROPHY  OF  THE   COLON.1 

This  is  a  rare  disease  seen  in  infants  and  older  children. 
There  is  hypertrophy  of  the  muscular  coats  of  the  colon, 
together  with  marked  constipation  and  distention  of  the  abdo- 
men. The  distention  may  disappear  temporarily  after  a  stool. 
The  patients  are  emaciated.  Some  die  early,  whilst  some 
live  to  be  adults.  The  treatment  is  symptomatic.  Treves 
has  operated  on  a  case  with  good  results. 

A  certain  amount  of  simple  dilatation  of  the  colon  is  seen 
in  infants  with  chronic  constipation,  especially  the  rachitic 
ones.     This  usually  disappears  during  early  childhood. 

1  Osier,  Archives  of  Pediatrics,  February,  1893,  p.  111. 


DISEASES  OF  THE  INTESTINES. 


171 


INTESTINAL  WORMS.1 
Cestodes  (Tapeworms).— The  eggs  of  these  worms  are 
taken  into  the  body  of  certain  animals  (intermediary  host), 

and  the  embryos  are  set  free 
in  the  stomach.  These  em- 
bryos migrate  and  become  en- 
cysted in  the  muscles.  When 
such  meat  is  eaten  by  man  the 
embryo  is  set  free  and  attaches 
itself  to  the  mucous  membrane 
of  the  bowel  and  grows  into  an 
adult  worm.  The  eggs  are 
contained  in  the  mature  seg- 
ments, which  are  furnished 
with  the  male  and  female 
sexual  organs. 

Taenia  Mediocanellata  or 
Saginata  (The  Beef  Tape- 
worm).— This  is  the  common 
tapeworm  of  America.      In- 


Fig.  4o.-T£enia  mediocanellata :  Small         Fig.  46. -Taenia  elhptica  (Mosler 
portions  from  different  parts  in  the  length  and  Peiper). 

of  the  tapeworm  (J.  P.  C.  Griffith). 

^Schloss,  "Helminthiasis  in  Children,"  Amer.  Jour,  of  Med,  f«.,voL 
cxxxix.,  1910,  p.  675.    Still,  "  Thread- worms,"  Brit.  Med,  Jour.,  Apr.  lo,  1899. 


172 


DISEASES  OF  INFANTS  AND  CHILDREN. 


fection  takes  place  from  eating  "measly"  beef.  The  adult, 
worm  is  from  ten  to  twenty  feet  long.  The  head  has  four 
suckers,  but  no  hooks.  The  adult  segments  are  about  as  long 
as  they  are  broad. 

Taenia    Solium    {The    Pork    Tapeworm). — This  is  rare  in 

America.  It  is  shorter  than  the 
preceding,  and  the  head  has  four 
suckers  and  a  circle  of  booklets 
about  the  proboscis.  The  adult 
segments  are  nearly  square. 

Hymenolepis  Nana  (The  Dwarf 
Tapeworm). — This  will  doubtless 
prove  a  common  parasite  in  Amer- 
ica. It  is  the  smallest  cestode  par- 
asite affecting  man.  The  worms  are 
present  in  great  numbers.  The 
ova  are  found  in  the  feces,  are  col- 
orless or  brownish,  and  are  easily 
seen  with  the  low  power  of  the 
microscope.  The  eggs  have  two 
membranes,  and  the  six  hooklets  of 
the  embryo  are  seen  inside.  The 
worm  is  from  12  to  15  mm.  long  and 
0.5  to  0.7  mm.  broad  at  its  widest 
part,  There  are  from  110  to  200 
segments.     It  is  delicate  and  easily 


i 


broken.     The  head  has  suckers  and 


worm 


has 


hooklets.      A    similar 
been  found  in  rats.1 

Taenia  Cucumerina  or  Elliptica. — 
The  embryos  are  found  in  dog  and 
cat  lice.  Infection  occurs  by  get- 
ting the  embryos  on  the  hand  from 
dogs  or  cats.  The  adult  is  from  six 
to  twelve  inches  long. 
Bothriocephalus  latus,  the  fish  tapeworm,  and  Tarnia  flava 
punctata  are  rare  forms  occasionally  met  with. 

1  Bulletin  No.  18,  Hygienic  Laboratory  of  the  Public  Health  and  Marine 
Hospital  Service,  1904. 


Fig.  47.— Ascaris  lumbri- 
coides  :  A,  Female ;  B,  male ;  C, 
egg  (X  300) ;  b,  head  (magnified) 
(after  Perls). 


DISEASES  OF  THE  INTESTINES.  173 

Symptoms. — There  are  no  distinctive  symptoms,  but  in- 
creased appetite,  unpleasant  abdominal  symptoms,  bad  breath, 
and  sometimes  pain  and  diarrhea  are  complained  of.  Usually 
the  first  knowledge  of  the  parasite  is  the  finding  of  the  seg- 
ments in  the  stool.  This  is  the  only  certain  means  of  diag- 
nosing it.  Anemia  of  a  severer  grade  may  be  met  with  and 
the  bothriocephalic  may  cause  pernicious  anemia.  Eosino- 
philia  is  present. 

Prophylaxis. — Thorough  cooking  of  meat.  Careful  govern- 
ment inspection. 

Treatment. — Light  diet  for  a  day  and  a  laxative  to  empty 
the  bowel.  Oleoresin  of  male  fern  in  several  doses  at  inter- 
vals of  an  hour.  From  10  to  20  minims  may  be  given  at  a 
dose  to  children.  Give  a  purge  a  few  hours  after  the  anthel- 
mintic, and  a  milk  diet  for  the  remainder  of  the  day. 
Examine  the  stools  for  the  head,  which  is  about  the  size  of  a 
grain  of  mustard.  If  the  head  is  not  passed  the  worm  will 
grow  again.  Pelletierine  (3-12  gr.)  or  pumpkin  seed  (J  oz.) 
may  also  be  used. 

Nematodes. — Ascaris  Lumbricoides  (Roundworm). — The 
eggs  are  taken  in  with  water  or  food,  and  they  develop 
in  the  intestine  into  round  worms  from  4  to  6  inches  long, 
\  of  an  inch  in  diameter.  The  females  are  longer  than  the 
males.     A  number  are  present  at  one  time. 

Symptoms. — Often  none,  but  at  other  times  colic,  indiges- 
tion, loss  of  appetite,  disturbed  sleep,  picking  at  the  nose  and 
all  sorts  of  curious  reflex  nervous  symptoms,  such  as  convul- 
sions, vertigo,  and  paralyses.  Occasional  febrile  disturb- 
ances may  be  present.  Obstruction  of  the  bowel  has  been 
caused  by  masses  of  the  worms.  They  migrate  and  may 
crawl  out  of  the  nose  or  into  the  larynx  or  Eustachian  tube. 
Their  presence  in  the  stools  is  the  only  positive  way  to  diag- 
nose them. 

Treatment. — Empty  the  bowl  as  for  tapeworm,  then  give 
three  or  four  doses  of  santonin,  |  to  1  gr.  Follow  by 
castor  oil  or  calomel.  Give  the  santonin  in  powder  with 
sugar. 

Oxyuris  Vermicularis    (Seatworm;    Pinworm). — These   are 


174 


DISEASES  OF  INFANTS  AND   CHILDREN. 


small  round  worms  as  thick  as  a  pin  and  from  J  to  }  in.  in 
length.  They  are  found  in  the  lower  colon  and  rectum. 
They  cause  intolerable  itching  of  the  anus,  sometimes  proc- 


Fig.  48.— Oxyuris  vermicularis  and  egg  :  a,  Natural  size ;  b,  egg  (after  Heller). 

titis.     There  may  be  large  quantities  of  mucus  in  the  stools. 
They  may  cause  convulsions. 

Treatment. — Require  persistent  treatment.  Wash  out  the 
bowel  with  borax  and  water  (teaspoonful  to  the  pint)  and 
then  inject  half  pint  of  quinine  sulphate  solution  (2  gr.  to  1 
pint)  or  1  :  10,000  bichlorid  of  mercury.  Infusions  of 
quassia  or  garlic  are  also  useful.  Garlic  may  be  given  by 
the  mouth.     In  resistant  cases  try  santonin. 


DISEASES  OF  THE  RECTUM. 

Prolapse  of  the  Anus.1 — This  may  be  simply  of  the 
mucous  membrane,  or  the  entire  rectum  may  be  everted.  It 
is  most  frequent  in  the  second  and  third  year  and  is  fre- 
quently caused  by  prolonged  straining  at  stool. 

Symptoms. — Usually  occurs  at  stool  and  frequently  can 
be  easily  reduced.  Where  several  inches  of  the  rectum  are 
everted  there  is  a  red  tumor-like  mass  which  may  be  more 
or  less  difficult  to  return. 

Treatment. — Oil  the  finger  and  return  by  pressure. 
Keep  the  child  quiet  for  an  hour  afterward.  If  difficult  to 
return  apply  cold  cloths.  Painting  with  4  per  cent,  cocain 
may  be  used  in  obstinate  cases.  In  recurring  cases  have 
child  defecate  on  its  back  or  while  using  a  seat  inclined  to 

1  Kelsey,  "  Prolapse  of  the  Rectum,"  Archives  of  Pediatrics,  1885. 


DISEASES  OF  THE  INTESTINES. 


175 


an  angle  of  45  degrees.  Keep  the  bowels  well  open.  Inject 
tannic  acid  (5  grs.  to  J  oz.)  water  twice  daily  or  anoint  with 
belladonna  ointment.  A  pad  and  a  T  bandage  may  be  used 
as  a  support  where  the  bowel  tends  to  come  down  between 
stools.  Local  injections  of  strychnia  (y^o  Sr0  or  nnear 
marking  with  the  cautery  may  be  tried. 

Fissure  of  the  Anus. — Looks  like  a  tear  or  an  ulcer- 
ated surface.     Causes  very  great  pain,  especially  at  stool. 

Treatment. — Keep  clean  and  the  bowels  open.  Touch 
with  nitrate  of  silver.  If  not  relieved  anesthetize  and  stretch 
the  sphincter  of  the  anus. 


Fig.  49.— Prolapsus  of  the  rectum  (after  Bryant). 

Irritation  of  the  Anus  and  Hemorrhoids. — Irri- 
tation of  the  anus  is  frequent,  while  hemorrhoids  are  com- 
paratively rare.  Constipation  should  be  relieved,  the  child 
should  be  kept  clean,  and  the  following  ointment  used 
liberally : 


li    Tannic   acid, 

Powdered  camphor, 

Ichthyol, 

Zinc  oxid  ointment, 


gr.  x ; 
gr.  v ; 
3iss; 
3J.— M. 

(Kerley.) 


Proctitis. — This  occurs  with  inflammations  of  the  colon, 
but  may  occur  alone  from  suppositories,   pin  worms,  gonor- 


176  DISEASES  OF  INFANTS  AND   CHILDREN. 

rhea,  or  from  syphilis,  scarlet  fever,  measles,  and  other  infec- 
tious diseases.  It  may  be  catarrhal,  ulcerative,  or  mem- 
branous. 

Treatment. — Regulate  the  bowels.  Magnesia  or  sodium 
bicarbonate  by  mouth  if  stools  are  acid.  Keep  clean  with 
normal  salt  solution  injections,  follow  with  injections  of  oil 
and  lime-water  in  the  acute  cases,  fluid  extract  of  hamamelis, 
teaspoonful  to  the  pint  in  the  chronic  forms,  and  boric  acid 
in  the  ulcerative  cases.  Nitrate  of  silver  (1  gr.  to  the 
ounce)  may  be  used  in  very  resistant  cases.  Neutralize  the 
excess  of  silver  with  salt  solution. 

Incontinence  of  Feces. — Seen  in  injuries  and  diseases 
of  the  spinal  cord,  in  comatose  conditions,  and  in  very  severe 
illness  of  any  kind.  Is  also  sometimes  seen  in  very  nervous 
children.  This  last  form  may  be  benefited  by  local  injec- 
tions of  strychnia  (y^  gr-)  twice  daily  and  by  using  ergot  in 
a  suppository  or  by  mouth. 

PERITONITIS. 

All  forms  of  peritonitis  are  rare  in  early  life. 

Acute  Peritonitis. — In  the  newborn  it  may  be  caused 
by  infection  through  the  umbilicus.  In  later  childhood  it 
may  follow  wounds,  surgical  operations,  burns,  and  exposure. 
It  may  be  a  sequela  of  appendicitis  or  be  caused  by  an  ex- 
tension of  other  purulent  inflammations  or  it  may  be  a  com- 
plication of  the  infectious  diseases. 

Pathology. — It  may  be  localized  or  general.  It  may  be 
fibrinous,  serous,  or  purulent,  according  to  the  nature  of  the 
exudate.     Adhesions  are  frequent. 

Symptoms. — Sudden  onset,  vomiting,  usually  high  fever, 
crying,  and  fretfulness.  The  abdomen  is  distended,  tym- 
panitic, and  tender.  The  muscles  are  rigid.  There  may  be 
convulsions  or  collapse.  In  young  infants  it  may  be  found 
at  autopsy  where  it  was  not  suspected  during  life. 

Prognosis. — In  infants  it  is  very  fatal,  the  average  duration 
being  four  days.     In  older  children  the  outlook  is  better, 


DISEASES   OF  THE  INTESTINES.  177 

especially  if  the  inflammation  becomes  localized.  If  the  child 
lives  over  a  week  the  chances  are  then  much  better. 

Treatment. — An  initial  purge  of  calomel  or  a  saline  or 
both,  opium  in  some  form  for  the  pain,  stomach  washing  if 
there  is  vomiting,  high  saline  injections  into  the  rectum  sev- 
eral times  daily.  Abdominal  applications  of  cold,  heat,  or 
counterirritants  may  be  used.  Do  not  irritate  the  skin  if  a 
surgical  operation  is  to  be  performed.  Careful  feeding  with 
liquid  predigested  foods.  Stimulants  as  required.  Surgical 
operation  may  be  indicated.  Exploratory  laparotomy  and 
the  evacuation  of  pus  may  be  considered. 

Chronic  (Non-tuberculous)  Peritonitis. — This  is  a 
rare  disease  of  late  childhood.  The  cause  is  unknown.  It 
has  been  supposed  to  follow  measles,  rheumatism,  and  ex- 
posure. There  is  usually  a  considerable  serous  exudate  with 
fibrin  flakes.     Numerous  adhesions  are  present. 

Symptoms. — Gradual  enlargement  of  the  abdomen,  which 
is  somewhat  tender.  There  is  gradual  loss  of  weight  and 
strength.  There  is  slight  fever,  as  a  rule.  The  disease  runs 
an  irregular  course  with  periods  of  improvement  and  relapses. 

Diagnosis  on  above  symptoms  with  absence  of  evidence  of 
disease  of  other  organs.     (See  Tuberculous  Peritonitis.) 

Treatment. — Rest,  careful  diet,  restricted  fluid,  and  salines. 
The  abdomen  may  be  opened  and  flushed  out  with  salt  solu- 
tion. 


ASCITES. 

An  effusion  of  fluid  into  the  peritoneal  cavity.  It  is  usually 
a  clear  serous  fluid,  but  may  be  bloody  (sometimes  in  tubercu- 
lous or  malignant  disease)  or  milky.     (See  Chylous  Ascites.) 

It  may  be  part  of  a  general  edema,  as  in  heart  disease, 
chronic  pleurisy,  interstitial  pneumonia,  nephritis,  anemia, 
etc.,  or  it  may  be  due  to  portal  obstruction  caused  by  cir- 
rhosis of  the  liver  or  the  pressure  of  a  gland  or  adhesions 
on  the  portal  vein,  or  it  may  be  seen  when  there  is  an 
abdominal  tumor. 

12 


178 


DISEASES  OF  INFANTS  AND   CHILDREN. 


The  abdomen  is  enlarged,  and  the  fluid  can  usually  be 
made  out  by  fluctuation  or  by  the  alteration  in  the  position 
of  dulness  on  changing  the  position  of  the  patient. 


Fig.  50.— Omental  cyst.    (Courtesy  of  Dr.  J.  N.  Mendelsohn.) 


CHYLOUS  ASCITES.1 

Ascites  in  which  the  fluid  contains  fat,  giving  it  a  milky 
appearance.  Simple  or  tuberculous  peritonitis  may  be  present. 
It  has  been  caused  by  wounds  in  the  thoracic  duct,  but  also 
occurs  where  the  lymphatics  appear  normal.  The  prognosis 
is,  as  a  rule,  bad.     Treatment  as  in  tuberculous  peritonitis. 

1  Letulle,  Revue  de  Medecine,  1884,  No.  9. 


DISEASES  OF  THE  LIVER.  179 

DISEASES  OF  THE    LIVER. 

Icterus. — Jaundice  is  only  a  symptom,  and  may  be  due 
to  a  number  of  different  causes.  These  may  be  either 
obstructive  or  toxic.  Under  the  first  heading  may  be  men- 
tioned stricture  or  obliteration  of  the  ducts  ;  inflammation  of 
the  ducts,  as  in  catarrhal  jaundice ;  foreign  bodies  in  the 
duct,  as  a  roundworm  ;  and  pressure  on  the  ducts  from  an 
enlarged  gland  or  tumor.  The  toxic  forms  are  sometimes 
seen  in  malaria,  scarlet  fever,  Weil's  disease,  and  other 
infectious  diseases. 

Icterus  in  the  newborn  is  usually  the  physiologic  jaundice,  but 
maybe  stricture  or  occlusion  of  the  duet  or  WinckePs  disease. 
In  older  children  icterus  is  nearly  always  the  catarrhal  jaundice: 
all  other  causes  of  icterus  are  extremely  rare  in  children. 

The  skin  is  yellow,  and  the  secretions,  urine,  etc.,  are  tinged 
yellow  and  contain  bile  pigment,  the  stools  are  whitish  and  very 
offensive,  there  is  a  great  irritability  and  many  other  nervous 
symptoms,  and  also  a  tendency  to  hemorrhage.  Slow  pulse  and 
itching  of  the  skin  are  not  common  until  after  seven  years  of  age. 

Acute  congestion  of  the  liver  may  be  met  with  as 
in  the  enlarged  and  tender  liver  of  malaria.  Chronic  con- 
gestion results  from  general  venous  obstruction,  as  in  heart 
and  lung  diseases.  The  liver  is  enlarged,  but  there  are 
rarely  symptoms  referable  to  it. 

Patty  liver  is  common  in  infancy  and  childhood.  About 
half  the  cases  autopsied  show  this  lesion.  Tuberculosis  is  a 
frequent  cause.  The  liver  is  enlarged,  sometimes  enor- 
mously so.  It  is  smooth  and  has  rounded  edges  and  is  not 
tender.  There  are  no  symptoms  referable  to  the  liver. 
Treat  the  accompanying  disease. 

Amyloid  liver  is  seen  as  a  sequela  of  long-standing 
suppuration,  especially  of  the  bones.  It  is  supposed  to  be 
due  to  poisoning  with  the  toxins  of  the  staphylococcus  pyo- 
genes aureus.  Amyloid  changes  are  present  in  the  other 
organs,  and  there  is  always  an  enlarged  spleen.  The  liver  is 
enlarged,  hard,  waxy,  and  gives  a  characteristic  brown  reac- 
tion with  iodin.  There  is  no  jaundice  and  no  symptoms 
referable  to  the  liver.     Edema,  ascites,  and  albuminuria  may 


180  DISEASES  OF  INFANTS  AND  CHILDREN. 

be  present  from  the  kidney  degenerations  or  from  pressure. 
The  condition  is  chronic  and  usually  means  a  grave  prog- 
nosis. The  treatment  is  to  get  rid  of  the  focus  of  suppura- 
tion.    Antisyphilitic  treatment  should  be  given  if  indicated. 

Cirrhosis  of  the  liver l  is  very  rare  in  infancy  and 
childhood.  In  infancy  it  is  usually  syphilitic,  while  in  older 
children  the  cause  is  obscure  and  probably  due  to  infectious 
diseases.  The  morbid  anatomy,  symptoms,  and  treatment 
are  as  in  adults.     Antisyphilitic  treatment  should  be  tried. 

Abscess 2  of  the  liver  is  rare  in  early  life.  It  may  be 
due  to  the  migration  of  roundworms,  or  may  be  secondary 
to  suppuration  elsewhere  in  the  abdomen  or  may  be  seen  as  a 
complication  of  an  infectious  disease. 

Symptoms  are  chills,  fever,  and  sweats,  pain  in  liver  or 
referred  to  other  regions,  vomiting,  diarrhea,  loss  of  weight, 
and  a  septic  appearance.  Mild  icterus  is  present  in  about 
half  the  cases.  The  liver  is  enlarged  and  fluctuation  may  be 
made  out.     Treatment  is  incision  and  drainage. 

Gallstones 3  are  very  rare  in  early  life.  They  may,  how- 
ever, be  met  with  in  infants,  where  it  is  a  fatal  condition. 

Hydatid  cysts  may  be  met  with  in  childhood,  but  this 
disease  is  practically  unknown  in  America. 

Acute  yellow  atrophy4  has  been  reported  as  early  as 
the  twentieth  month. 

CHRONIC  FAMILY  JAUNDICE.5 
A  peculiar  form  of  jaundice  may  be  seen  in  several  members 
of  a  family,  sometimes  in  two,  three,  or  even  four  generations. 
It  does  not  interfere  with  growth,  and  may  be  present  from 
birth.  There  is  a  mild  icterus  with  the  other  symptoms,  usu- 
ally present  with  jaundice  or  absent.  The  spleen  is  enlarged 
and  there  is  a  moderate  anemia.  Bilious  attacks  are  common. 
There  is  no  known  treatment  that  influences  the  conditiou. 

1  Howard,  American  Journal  of  the  Medical  Sciences,  1887,  p.  350. 

2  Musser,  Keatiug's  Cyclopedia,  vol.  iii.,  p.  466. 

3  John  Thomson,  Edinburgh  Hospital  Reports,  1898. 

i  A.  H.  Wentworth,  "  Yellow  Atrophy,  Acute,"  Archives  of  Pediatrics, 
February,  1906,  p.  81.  Clark  and  Dalley,  "  Hepaptosis,  Congenital,"  Amer- 
ican Journal  of  the  Medical  Sciences,  December,  19U5,  p.  969. 

5  Tileston  and  Griffin,  American  Journal  of  the  Medical  Sciences,  June, 
1910,  p.  847. 


THE  RESPIRATORY  SYSTEM.  181 

THE  RESPIRATORY  SYSTEM  OF  INFANTS  AND 

CHILDREN, 

Respiration  according  to  Uffelmarm  : 

At  birth 35 

End  of  first  year -±~ 

At  second  year 25 

At  sixth  year 22 

At  twelfth  year 20 

At  birth  the  anterior  and  posterior  diameter  of  the  chest 
arc  about  the  same,  and  the  thorax  nearly  the  same  size  at 
the  top  and  bottom,  or  cylindric  in  shape.  Later,  about 
the  third  year,  it  becomes  flattened,  and  this  increases  until 
puberty,  when  the  chest  is  wider  below  and  being  pointed 
like  a  cone  above.  The  greatest  part  of  the  lung  in  in- 
fants and  young  children  is  at  the  back.  One  should  also 
remember  that  in  early  childhood  the  chest  walls  are  thinner 
and  softer,  and  changes  in  shape  due  to  disease,  as  in  pleural 
effusion,  are  more  frequent  than  in  later  life.  The  diaphragm 
is  higher,  and  may  be  still  further  pushed  up  by  gas  in  the 
stomach  and  intestines,  the  frequent  source  of  dyspnea  in  dis- 
eases of  the  lung  in  the  young.  The  thymus  is  larger  and 
occupies  a  considerable  portion  of  the  anterior  part  of  the 
mediastinum.  The  respiration  in  the  infant  is  more  or  less 
irregular  when  it  is  awake,  and  the  movements  of  the  two 
sides  of  the  chest  may  be  unequal.  After  the  second  year 
there  is  the  tendency  for  the  respiration  to  become  more  reg- 
ular, and  it  is  also  regular  when  the  child  is  asleep.  The 
chest  walls  move  less  in  children  and  the  diaphragm  more, 
so  that  the  respiration  rate  is  more  easily  counted  by  watch- 
ing the  epigastrium.  About  the  sixth  year  and  later  the 
respiration  becomes  more  like  that  of  adults.  The  trachea  and 
bronchi  are  relatively  much  larger  than  in  adults,  while  the 
air  cells  are  smaller  and  there  is  more  interstitial  tissue. 
The  percussion  note  is  louder  and  more  resonant  than  in  older 
people,  owing  to  the  thinner  chest  wall  and  the  larger  bronchi. 
Abdominal  tympany  is  more  easily  transmitted.  Between 
the  scapulas  and  below  the  clavicles  the  note  is  often  tym- 


182  DISEASES  OF  INFANTS  AND  CHILDREN. 

panitic,  rather  more  pronounced  on  the  right  side.  Cracked- 
pot  sound  can  frequently  be  elicited  even  in  health  in  these 
regions.  The  thymus  dulness  can  frequently  be  made  out 
over  the  upper  part  of  the  sternum,  especially  in  children  of 
the  lymphatic  type.  The  respiratory  murmur  is  more  bron- 
chial than  in  later  life.  This  may  be  mistaken  for  bronchial 
breathing.  Bronchial  rales  may  be  mistaken  for  friction- 
rubs.  Flatness  on  percussion  usually  means  fluid,  even 
though  bronchial  breathing  is  plainly  heard.  Absence  of 
dulness  does  not  exclude  consolidation,  as  the  note  may  be 
aifected  by  small  areas  of  supervening  normal  or  emphy- 
sematous lung. 

CORYZA.1 
(Acute  Rhinitis,  Cold  in  the  Head.) 

Definition. — An  acute  inflammation  of  the  nasal  cavities 
and  of  the  rhinopharynx. 

Etiology. — Most  frequent  in  children  housed  too  closely. 
Is  brought  on  by  exposure  to  cold  and  wet,  irritating  vapors, 
and  is  seen  as  a  complication  of  infectious  diseases,  especially 
measles,  influenza  and  nasal  diphtheria,  and  as  a  symptom 
of  iodism.  The  associated  organisms  are  most  frequently  the 
micrococcus  catarrhalis,  micrococcus  paratetragenous,  bacillus 
septicus,  Friedlander's  bacillus,  and  it  is  probable  that  the 
pneumococcus  and  the  bacillus  of  influenza  may  be  associated 
with  mild  catarrhs. 

Pathology. — The  mucous  membranes  are  reddened  and 
swollen ;  later  there  is  a  profuse  discharge. 

Symptoms. — It  begins  with  sneezing,  malaise,  fulness 
in  the  head,  and  after  the  onset  a  profuse  discharge  which 
may  become  mucopurulent.  The  nostrils  may  be  occluded 
by  the  swelling,  and  the  child  breathes  through  the  mouth. 

Complications. — Adenitis  may  follow  in  young  infants. 
Conjunctivitis  or  catarrh  of  the  middle  ear  may  be  present. 

Diagnosis. — Examine  for  diphtheritic  membrane  and  in 
young  infants  for  syphilis.  In  measles  and  influenza  there 
is  more  constitutional  disturbance,  and  in  measles  Koplik 
spots  may  be  present. 

1  Allen,  "  The  Common  Cold,"  Lancet,  December  5,  1908. 


THE  RESPIRATORY  SYSTEM.  183 

Prognosis. — Good. 

Treatment. — Open  the  bowels,  keep  in  a  warm  room 
(70°  F.)  and  give  light  diet.  Atropin  gr.  YGTV  ^or  eaca 
year  of  the  child's  age,  or  belladonna.  In  older  children  a 
quarter  of  a  grain  of  camphor  and  qninin  may  be  added. 
Use  cleansing  sprays,  as  Dobell's  or  Seller's  solution,  and  fol- 
low by  oily  applications,  as 

R.  Menthol      gr.  v     (0.3); 

Eucalyptol gr.  vi  (0.4); 

Camphor gr.  v    (0.3)  ; 

Liquid  petrolatum 5J       (30.0). — M. 

Sig. — Use  in  an  oil  atomizer  after  cleansing  the  nose. 

CHRONIC  NASAL  CATARRH. 

( Chronic   Rhinitis. ) 

Chronic  inflammation  of  the  nasal  mucous  membranes  may 
be  due  to  a  number  of  different  causes.  Among  them  are  aden- 
oids, deviation  of  the  septum,  hypertrophy  of  the  mucous 
membrane,  polypi,  repeated  attacks  of  coryza,  and  syphilis. 
A  one-sided  nasal  discharge  is  usually  due  to  a  foreign  body 
in  the  nose  or  to  a  new  growth  or  tertiary  syphilis. 

Symptoms. — A  mucous  or  mucopurulent  discharge  from 
the  nose,  mouth-breathing,  obstruction  of  the  nostril,  nasal 
voice,  diminution,  or  loss  of  the  sense  of  smell,  irritation  of 
the  upper  lip,  frontal  headache,  and  catarrh  of  the  neighbor- 
ing organs. 

Three  varieties  are  described :  simple,  hypertrophic,  and 
atrophic. 

Simple  Rhinitis. — This  is  rare  in  children,  and  when  seen 
is  usually  due  to  adenoids.  There  is  profuse  discharge  and 
swelling  of  the  mucous  membranes.  Prognosis  is  good  if 
the  cause  is  removed. 

Hypertrophic  Rhinitis. — This  is  rare  in  early  childhood, 
but  it  is  seen  in  older  children.  The  tissues  covering  the 
turbinated  bones  are  inflamed  and  thickened.  Adenoids  are 
usually  present.  There  is  marked  nasal  obstruction  and  a 
mucopurulent  discharge.  Prognosis  is  good  if  persistent 
treatment  is  carried  out. 


184  DISEASES  OF  INFANTS  AND  CHILDREN. 

Atrophic  Rhinitis. — This  is  occasionally  seen  in  late 
childhood.  The  mucous  membranes  of  the  nose  are  atrophied, 
and  there  is  a  scanty  discharge  which  tends  to  dry  and  form 
crusts  which  cause  a  very  disagreeable  odor.  The  sense  of 
smell  of  the  patient  is  usually  lost.  This  form  can  be  relieved 
by  constant  treatment,  but  a  cure  is  not  to  be  expected. 

Treatment. — The  health  of  the  child  should  be  looked 
after,  and  it  should  have  plenty  of  fresh  air,  good  food,  and 
tonics.  Adenoids  and  obstructions  should  be  removed. 
Hypertrophies  may  be  cauterized  if  they  persist  after  local 
applications.  In  all  cases  cleansing  sprays  should  be  used.  In 
the  hypertrophic  form  apply  astringents  to  the  mucous  mem- 
brane (6  gr.  of  iodin,  12  gr.  of  potassium  iodid,  and  1  oz. 
each,  of  glycerin  and  water  ;  J  per  cent,  solutions  of  silver  ni- 
trate ;  20  to  40  per  cent,  aqueous  solutions  of  ichthyol).  In 
the  atrophic  form  the  nose  must  be  cleansed  twice  daily  with 
copious  douches  of  hot  antiseptic  solutions  and  oily  sprays 
used  to  keep  the  mucous  membranes  moist.  Solutions  of 
potassium  permanganate,  formaldehyd,  or  peroxid  of  hydro- 
gen may  be  used  to  lessen  the  intolerable  odor. 

Syphilitic  Rhinitis.— In  early  hereditary  syphilis  this 
is  a  most  constant  symptom,  coming  on  usually  between  the 
third  and  sixth  week.  There  is  a  profuse  discharge  and  the 
child  sniffles. 

In  late  hereditary  syphilis,  rhinitis  is  usually  due  to  the 
breaking  down  of  a  gumma,  with  subsequent  ulceration  and 
necrosis,  which  may  be  very  extensive.  The  bridge  of  the 
nose  may  sink  in. 

Membranous  Rhinitis. — This  is  almost  without  ex- 
ception diphtheritic  and  should  be  treated  as  such. 

ADENOID  VEGETATIONS  OF  THE  VAULT  OF  THE 
PHARYNX  (Meyer,  J868).1 

Definition. — Hypertrophy  of  the  mass  of  lymphoid  tis- 
sue normally  present  in  the  vault  of  the  pharynx,  and  often 
called  the  pharyngeal  tonsil. 

1  Glogau,  "  Nasal  Obstruction  in  Children,"  Am.  Med.,  April,  1909,  p.  195. 


THE  RESPIRATORY  SYSTEM.  185 

Etiology. — Often  hereditary,  frequently  .-ecu  in  rachitic 
children,  and  also  a  part  of  the  general  lymphatic  enlarge- 
ment known  as  "lymphatism."  A  small  percentage  are  of 
tuberculous  origin,  and  in  others  they  are  first  noted  after 
some  acute  infectious  disease  or  after  frequent  colds. 

Symptoms. — May  be  present  at  birth,  but  usually  not 
until  the  child  is  several  years  old.  The  symptoms  increase 
with  the  age  of  the  child  until  about  puberty,  when  there  is 


Fig.  51.— Adenoid  vegetations. 


a  gradual  atrophy  of  the  adenoid  tissue  and  a  lessening  of 
the  symptoms. 

Adenoids  cause :  Chronic  rhinopharyngitis  with  frequent 
attacks  of  coryza,  especially  in  winter. 

Obstruction  of  the  air-passages  causing  mouth-breathing, 
which  may  be  constant  or  only  when  the  child  lies  down,  a 
nasal  twang  to  the  voice,  inability  to  blow  the  nose,  attacks 
of  dyspnea  at  night  and  night  terrors  ;  a  dyspnea  on  lying 
on  the  back,  consequently  the  child  in  sleep  assumes  other 
positions.  There  is  frequently  a  paroxysm  of  coughing 
which  may  be  mistaken  for  whooping-cough.  The  child  fre- 
quently snores  at  night,  and  there  may  be  enuresis.  There 
is  also  frequent  deformity  of  the  chest,  due  to  deficient 
expansion  (pigeon-breast),  most  marked  in  rachitic  chil- 
dren. 


186  DISEASES  OF  INFANTS  AND   CHILDREN. 

In  infants  adenoids  may  cause  difficulty  in  sucking,  so  that 
the  child  takes  only  sufficient  food  to  satisfy  the  pangs  of 
hunger,  is  consequently  underfed,  and  malnutrition  follows. 
There  are  also  frequent  attacks  of  coryza,  bronchitis,  and 
even  a  catarrhal  laryngitis  and  croup. 

Deafness  of  a  more  or  less  severe  grade  is  present  in  nearly 
every  case.  This  may  be  due  to  otitis  or  to  obstruction  of 
the  Eustachian  tube.  Mental  dulness  and  apathy,  indis- 
position to  exertion,  anemia,  and  general  malnutrition  are 
also  present.      Enuresis  is  also  frequently  present. 

Diagnosis. — The  above  symptoms  and  the  typical  ex- 
pression of  nasal  obstruction  should  lead  to  a  digital  exami- 
nation. The  growths  are  easily  felt  by  the  finger,  except  in 
young  infants  or  children  with  a  very  small  nasal  pharynx. 
In  these  latter  the  diagnosis  may  often  be  made  by  lifting  up 
the  soft  palate,  when  in  young  infants  the  adenoid  growths 
may  usually  be  seen,  as  the  nasal  pharyngeal  vault  is  much 
lower  in  infants  than  in  older  children.  It  should  be  borne 
in  mind  that  mouth-breathing  may  sometimes  be  due  to  ob- 
struction in  the  nose,  and  careful  examination  for  this  should 
always  be  made. 

Prognosis. — This  is  good  if  the  growths  are  removed, 
and  the  earlier  the  operation  is  done  the  better  the  ultimate 
results.  If  delayed  until  after  puberty  the  breathing  may 
be  benefited,  and  by  that  time  there  may  be  incurable  de- 
formities of  the  chest  or  tuberculosis  or  deafness  may  have 
resulted. 

Treatment. — The  growths  should  be  removed  by  means 
of  a  curet,  best  under  the  first  stage  of  ether  anesthesia. 
Children  who  have  been  mouth-breathers  usually  have  to  be 
taught  to  breathe  through  the  nose  by  daily  breathing  exer- 
cises.    In  most  cases  a  local  astringent  may  be  tried  : 

R    Iodin,  gr.  \  to  £ ; 

Menthol,  gr.  j  ; 

Camphor,  gr.  v ; 

Liq.  petrolatum,  3j. — M. 

Sig. — Five  drops  in  each  nostril  three  or  four  times  a  day. 


THE  RESPIRATORY  SYSTEM. 


187 


DISEASES  OF  THE  LARYNX,1 

Note  that  in  all  laryngeal  affections  in  early  life  the 
amount  of  spasm  is  always  much  greater  than  the  amount  of 
disturbance  and  may  be  the  cause  of  the  principal  symptom. 

CATARRHAL  SPASM  OF  THE  LARYNX  (Goodhart). 
(Spasmodic  Croup;  Catarrhal  Croup;  Fake  Croup;  Spasmodic  Laryngitis.) 
Definition. — A  spasm  of  the  larynx  caused  by  a  mild 
catarrh. 


Fig.  52—  Croup  tent  (J.  P.  C  Griffith). 

Ktiology. — This  is  most  frequently  seen  between  the 
sixth  month  and  the  fourth  year,  in  certain  children 
who  are  predisposed  to  it  and  who  have  frequent  attacks. 
Exposure  to  cold  or  indigestion  is  usually  the  exciting 
cause. 

1  Sutherland  and  Lack,  "  Laryngoscopy,"  Lancet,  September  11,  1897. 


188  DISEASES  OF  INFANTS  AND  CHILDREN. 

Symptoms. — During  the  evening  the  child  has  a  barking 
cough  and  is  slightly  hoarse.  During  the  night  the  child 
wakes  with  a  hard  metallic  cough,  marked  dyspnea,  loss  of 
voice,  and  cyanosis.  There  is  a  loud  inspiratory  stridor. 
The  child  is  frightened  and  struggles  for  breath.     There  may 


Fig.  53.— Croup  kettle. 


Fig.  54.— Steam  atomizer. 


be  a  slight  fever.  After  an  hour  or  two  the  attack  wears  off, 
but  may  recur  the  same  night.  A  recurrence  is  to  be  looked 
for  on  the  two  or  three  following  nights,  but  during  the  day 
the  child  is  perfectly  well,  save  for  slight  cough  and  hoarse- 
ness. 

Diagnosis. — From  laryngismus  stridulus  (which  see) 
and  laryngeal  diphtheria  (membranous  or  so-called  true  croup, 
both  unfortunate  names).  The  sudden  onset,  the  spasmodic 
character  of  the  dyspnea  and  the  remissions,  together  with 
a  history  of  previous  attack,  usually  makes  the  diagnosis 
from  diphtheria  easy.  If  there  is  doubt,  give  a  little  chlo- 
roform.     The    catarrhal   spasm   relaxes    immediately  while 


THE  RESPIRATORY  SYSTEM.  189 

the  laryngeal  obstruction  from  a  diphtheritic  membrane  is 
unaffected. 

Prognosis. — ( rood. 

Treatment. — During  the  attack  relax  the  spasm  by 
applications  of  heat,  inhalations  of  steam  or  emetics.  Syrup 
of  ipecac,  in  tcaspoonful  doses  every  fifteen  minutes  until 
vomiting  occurs,  is  a  favorite  remedy.  A  tablet  of  antimony 
and  ipecac  (each  yi-g-  gr.)  is  also  efficient,  but  is  more 
depressing  it'  vomiting  does  not  occur  promptly.  To  prevent 
recurrence  a  dose  of  antipyrin  (1  to  3  gr.)  with  or  without 
sodium  bromid  or  codein  should  be  given  and  repeated  if 
necessary.  On  the  following  day  small  doses  of  ipecac 
(10—15  drops)  or  the  tablet  mentioned  should  be  given  every 
four  hours,  and  a  dose  of  antipyrin  with  or  without  codein 
at  night. 

ACUTE  CATARRHAL  LARYNGITIS. 

This  is  more  rare  than  catarrhal  spasm,  and  is  usually  due 
to  exposure  to  cold  or  to  irritating  vapors. 

Symptoms. — The  principal  symptoms  are  hoarseness, 
occasionally  aphonia,  pain  on  speaking  and  swallowing,  a 
barking  cough,  slight,  sometimes  high  fever,  and  attacks  of 
dyspnea.  The  vocal  cords  are  red  and  swollen.  Edema  of 
the  glottis  is  a  serious  complication. 

Diagnosis. — From  catarrhal  spasm  by  the  more  con- 
tinuous symptoms.  From  laryngeal  diphtheria  the  diagnosis 
may  be  difficult.  The  more  intense  symptoms  and  the  loss 
of  voice  suggest  diphtheria.  In  laryngeal  diphtheria  after 
the  first  twelve  hours  the  dyspnea  is  inspiratory  and  expira- 
tory, while  in  catarrhal  laryngitis  it  is  chiefly  inspiratory. 
With  diphtheritic  membrane  elsewhere,  enlarged  glands,  or 
albuminuria,  the  diagnosis  of  diphtheria  is  almost  certain. 
Make  cultures  from  the  larynx  and  watch  the  patient  closely. 

Prognosis. — This  is  usually  good  except  in  the  cases 
following  the  infectious  diseases  or  in  very  young  infants. 

Treatment. — Put  the  patient  to  bed,  open  the  bowels, 
give  ipecac  or  squills  to  reduce  the  spasm,  or  use  inhalations 
of  steam  from  water  to  which  tr.  benzoin  comp.  (1  dr.  to  1 


190  DISEASES  OF  INFANTS  AND  CHILDREN. 

pint)  has  been  added.  Hot  applications  may  be  used.  In- 
tubate if  dyspnea  is  urgent.  In  doubtful  cases  not  improving 
under  treatment  give  diphtheria  antitoxin. 

Membranous  Laryngitis  (True  Croup). — A  name  applied 
to  laryngeal  diphtheria.  Occasionally  a  membrane  may  form 
in  the  larynx  from  some  other  infection,  usually  strepto- 
coccus, as  a  complication  or  sequela  of  one  of  the  infectious 
diseases,  most  frequently  scarlet  fever  or  measles.  The 
symptoms  in  the  latter  are  nearly  similar  to  laryngeal  diph- 
theria (which  see). 

EDEMA  OF  THE  GLOTTIS. 

This  may  occur  as  a  part  of  general  edema,  as  in  nephritis, 
or  it  may  be  due  to  injury  or  to  the  extension  of  an  inflam- 
matory process  (submucous  laryngitis). 

Symptoms. — There  is  marked  inspiratory  dyspnea  with 
normal  expiration,  pain,  cough,  hoarseness,  and  dysphagia. 
Diagnosis  by  digital  examination. 

Treatment. — Scarification,  application  of  adrenalin  or 
astringents  (alum,  3—5  gr.  to  the  ounce),  external  application 
of  cold,  leeches  over  the  larynx,  tracheotomy  if  necessary. 
Intubation  is  of  no  service. 

CHRONIC  LARYNGITIS. 

Simple  I/aryngitis. — In  children  this  is  nearly  always 
caused  by  adenoids.     It  may  be  due  to  irritating  vapors. 

Symptoms. — There  are  hoarseness,  aphonia,  cough,  and  some 
expectoration.  Laryngoscopic  examination  is  difficult  and 
reveals  redness  and  swelling  of  the  vocal  cords  or  of  the 
entire  larynx. 

Treatment. — Remove  the  adenoids  and  use  cleansing  sprays, 
inhalations  of  benzoin,  etc.,  and  if  necessary  local  applica- 
tions of  astringents.  (Alum,  3-5  gr.  to  the  ounce ;  sulpho- 
carbolate  of  zinc,  1—3  gr.  to  the  ounce.) 

Tuberculous  laryngitis. — This  is  almost  unknown 
in  early  life  and  is  rare  in  later  childhood.  When  it  occurs 
there  is  tuberculosis  elsewhere,  usually  in  the  lungs. 


THE  RESPIRATORY  SYSTEM.  191 

Symptoms. — There  may  be  hoarseness,  aphonia,  cough,  pain, 
in  the  throat,  increased  on  swallowing,  speaking  or  coughing. 
Laryngoscopic  examination  shows  tuberculous  deposits  or 
ulcerations,  but  these  are  not  characteristic  of  tuberculosis. 

Diagnosis  on  general  condition. 

Treatment. — Keep  clean  with  sprays,  apply  astringents 
locally — nitrate  of  silver,  sulphate  of  zinc,  or  iodoform. 

Syphilitic  laryngitis. — Frequent  in  early  life  as  a 
symptom  of  early  hereditary  syphilis,  less  often  as  a  mani- 
festation of  late  hereditary  syphilis.  There  is  usually  ulcera- 
tion with  great  destruction. 

Symptoms. — These  are  the  same  as  in  other  forms  of 
chronic  laryngitis.  In  hereditary  syphilis  there  may  be  little 
or  no  pain.  There  is  nothing  characteristic  on  laryngoscopic 
examination.     The  diagnosis  is  on  the  general  condition. 

Treatment. — Iodid  of  potassium  and  mercury  internally. 
Local  applications  and  sprays  as  in  above.  Intubation  may 
give  great  relief. 

TUMORS  OF  THE  LARYNX. 

These  are  usually  papillomata,  but  granulations  following 
tracheotomy  may  be  seen. 

Symptoms. — These  are  the  same  as  any  form  of  chronic 
laryngitis,  but  there  is  slowly  increasing  dyspnea. 

Diagnosis  by  laryngoscopic  examination. 

Treatment. — Operation  by  a  specialist. 

FOREIGN  BODIES  IN  THE  LARYNX.1 

This  may  happen  by  the  inspiration  of  the  object  from  the 
mouth  during  laughing  or  crying.  It  causes  coughing  and 
dyspnea.  The  object  may  be  forced  out  by  the  coughing  or 
may  be  drawn  into  the  trachea  or  bronchi,  or  it  may  remain 
in  the  larynx.  Death  may  occur  from  suffocation.  If  drawn 
into  the  trachea  there  are  pain,  cough,  and  sometimes  bloody 

1  J.  P.  Clark,  "Papilloma  of  the  Larynx  in  Children,"  Boston  Med.  and 
Surg.  Jour.,  Sept.  28, 1905,  p.  377.  John  Kogers,  "  Larynx,  Chronic  Obstruc- 
tion of,"  Amer.  Jour.  2Ied.  Sci.,  Nov,  1905,  p.  293.  Clark,  "  Treatment  of 
Laryngeal  Papilloma,"  Boston  Med.  and  Surg.  Jour.,  Oct.,  1905. 


192  DISEASES  OF  INFANTS  AND  CHILDREN 

expectoration.     There  is  absence  of  breath-sounds,  according 
to  the  location  of  the  object.     Abscess  may  follow. 

Treatment. — Invert  the  patient  and  it  may  be  coughed 
out.  If  lodged  in  the  larynx  and  suffocation  is  imminent 
perform  a  tracheotomy.  Operation  for  removal  should  be 
done  by  a  skilful  surgeon. 

LARYNGISMUS  STRIDULUS. 

(Seepage  306.) 

CONGENITAL  LARYNGEAL  STRIDOR. 

Definition. — A  curious  stridor  or  crowing  sometimes 
seen  in  early  life,  coming  on  immediately  or  shortly  after  birth. 

Ktiology. — The  attacks  may  be  increased  by  excitement 
and  exposure  to  cold. 

Pathology. — There  is  an  increase  in  the  infantile  char- 
acter of  the  larynx,  the  sides  of  the  epiglottis  being  turned 
back  so  that  they  almost  meet,  making  the  opening  of  the 
larynx  smaller  and  of  a  peculiar  shape.  In  cases  lasting  a 
long  time  there  may  be  a  pigeon-breast  deformity  of  the  chest. 

Symptoms. — "  The  stridor  consists  of  a  croaking  sound, 
which  accompanies  inspiration  and  which  rises  to  a  high- 
pitched  crow  on  quicker  or  deeper  breathing.  Expiration  is 
usually  noiseless,  and  sometimes  when  the  inspiratory  noise 
is  loud  it  is  accompanied  by  a  short  croak "  (Thomson). 
There  is  little  or  no  cyanosis.  The  stridor  may  be  present 
all  of  the  time  or  may  intermit,  or  may  only  come  on  in 
attacks  due  to  excitement.  The  child  appears  otherwise 
normal  and  unconcerned.  There  is  no  disturbance  in  the 
voice.  The  disease  reaches  its  height  about  the  sixth  month, 
and  begins  to  diminish  and  usually  ceases  entirely  by  the 
eighteenth  month  or  the  second  year.  During  the  later 
months  the  stridor  only  comes  on  during  excitement. 

Diagnosis. — This  is  easy.  The  congenital  character  of 
the  disease  and  absence  of  other  symptoms  separating  it  from 
laryngismus  stridulus,  and  the  normal  cry  from  laryngitis 
and  papilloma  of  the  larynx.  There  may  be  croaking  in 
cases  of  adenoids,  which  disappears  on  their  removal,  and  in 
enlargement  of  the  mediastinal  lymph-nodes ;  this   latter  is 


THE  RESPIRATORY  SYSTEM.  193 

usually  coupled  with  marked  disturbance  of  health,  with 
hoarseness,  and  is  sometimes  suggestive  of  whooping-cough. 

Prognosis. — This  is  good.  > 

Treatment.—  Protect  the  child  from  excitement,  regulate 
the  diet  carefully,  and  have  the  child  out  of  doors  as  much 
as  possible. 

Diseases  of  the  Bronchi  and  Lungs. 
BRONCHITIS. 

Definition.— An  inflammation  of  the  mucous  membrane 
lining  the  bronchial  tubes  or,  in  infants,  of  the  entire  tube, 
characterized  by  cough,  expectoration,  soreness  about  the 
chest,  and  moist  and  dry  rales.  # 

Varieties.— Acute  catarrhal  bronchitis,  chronic  catarrhal 
bronchitis,  and  fibrinous  bronchitis. 

ACUTE  CATARRHAL  BRONCHITIS. 

Etiology. The  primary  form  usually  results  from  ex- 
posure to  cold,  wet,  or  draughts,  but  may  also  be  due  to 
irritating  vapors  or  dust.  The  secondary  form  is  seen  as  a 
complication  of  almost  all  of  the  infectious  diseases,  especially 
of  measles,  influenza,  and  pertussis. 

Pathology. — There  are  swelling  and  congestion  of  the 
mucous  membranes  lining  the  tubes,  together  with  an  inflam- 
matory exudate  mixed  with  mucus,  pus  cells,  and  desqua- 
mated epithelium.  The  ordinary  "cold"  is  a  tracheobron- 
chitis- the  severe  "cold"  involves  the  medium-sized  tubes, 
while' the  severe  forms  in  infants  extend  to  the  smallest 
tubes  (capillary  bronchitis). 

Symptoms.— In  Infants.— Bronchitis  of  the  larger  tubes 
(mild  form).  The  onset  is  gradual,  with  coryza,  pharyngitis, 
and  cough.  The  respiration  is  rapid  and  irregular,  and  there 
are  loud  rales  which  can  be  easily  heard  and  felt.  There 
may  be  fever  (100°-102°  F.).  Vomiting  may  result  from 
the  severe  coughing  spells.  The  attack  usually  lasts  about 
a  week.     Kelapses  are  common. 

Bronchitis  of  the  smaller  tubes,  capillary  bronchitis  (severe 


194  DISEASES  OF  INFANTS  AND   CHILDREN 

form).  The  onset  may  be  gradual  or  sudden.  All  the 
symptoms  of  the  mild  form  are  inereased.  There  may  be 
high  fever,  marked  dyspnea,  prostration,  and  cyanosis.  It 
may  resemble  a  pneumonia  for  a  few  days.  Death  may  take 
place  in  young  or  weak  infants  from  respiratory  failure  or 
from  suffocation  due  to  the  inability  to  cough  up  the  sputum. 
The  severe  stage  lasts  two  or  three  days  and  then  changes 
into  a  milder  form.  (For  differential  diagnosis,  see  Broncho- 
pneumonia.) 

In  Older  Children. — Either  mild  or  severe  forms  may  be 
seen,  but  there  is  little  tendency  to  extend  into  the  smaller 
tubes.  The  symptoms  as  given  in  the  mild  form  in  infants 
are  present.  The  breathing  is  less  rapid  and  more  regular, 
and  the  cough  is  more  pronounced.  In  the  severe  forms 
there  are  fever,  pain  in  the  head  and  chest,  and  general  malaise. 
The  attack  lasts  from  one  to  three  weeks.  Relapses  are 
frequent. 

Prognosis. — In  weak  and  young  (under  six  months)  in- 
fants the  severe  form  may  prove  fatal.  In  strong  ones  (over 
six  months)  the  outlook  is  good. 

Prophylaxis. — Well-ventilated  rooms,  neither  too  hot 
nor  too  cold.  Cold  sponging  over  neck  and  chest,  night  and 
morning.     Cod-liver  oil  every  winter  to  susceptible  children. 

Treatment. — Keep  indoors  and,  if  there  is  fever,  in  bed. 
Open  the  bowels  and,  if  seen  early,  sweat  by  means  of  a  hot 
bath  (foot  or  full)  and  Dover's  Powder  and  phenacetin. 
Rub  chest  with  camphorated  oil.  If  fever  is  not  too  high 
use  an  oiled-silk  jacket  over  the  chest.  In  severe  forms  use 
counterirritation  over  the  chest ;  a  mustard  plaster  just  to 
redden  the  skin  is  best.  This  may  be  repeated  every  three 
or  four  hours.  In  the  first  stage  inhalations  of  steam  from 
lime  water ;  later  from  creosote  or  compound  tincture  of  ben- 
zoin (1  dr.  to  pint  of  water).  Strychnin  and  atropin  may  be 
used  to  stimulate  respiration,  and  alcohol  given  if  the  heart  is 
weak.  Attacks  of  suffocation  are  best  treated  by  hot  bath, 
mustard  plaster,  and  stimulants.  In  mild  cases  in  infants 
the  Jackson  mixture  containing  syrup  of  squills  may  be 
used ;  otherwise  in  infants  it  is  best  to  avoid   expectorants. 


THE  RESPIRATORY  SYSTEM.  195 

Id  older  children  squills,  ipecac,  6r  Dover's  powder  in  the 
dry  stage.  Later,  ammonium  muriate  and  mistura  glycyr- 
rhiza  composite  or  citrate  of  potassium  may  be  used.  If 
there  is  pain  and  cough  is  troublesome,  codein  with  antipyrin 
or  phenacetin  may  be  used.  Heroin  hydrochlorate,  with  or 
without  terpin  hydrate,  may  be  used  if  the  cough  is  exces- 
sive. For  persistent  bronchitis  creosote  or  terebene  is  best. 
Cod-liver  oil  may  be  used  during  convalescence.  A  change 
of  air  is  advisable  where  circumstances  allow. 

FIBRINOUS  BRONCHITIS* 

Primary  fibrinous  bronchitis  is  a  rare  disease,  more  fre- 
quent in  children  than  in  later  life.  A  secondary  form  may 
be  seen  complicating  laryngeal  diphtheria.  Casts  or  strings 
of  mucus  are  expectorated,  and  the  diagnosis  rests  on  finding 
the  casts.  The  symptoms  are  like  ordinary  bronchitis,  but 
there  are  fewT  or  no  rales.  It  may  become  chronic,  attacks 
occurring  every  few  days  or  weeks.  The  acute  form  is  fre- 
quently fatal  (75  per  cent.),  but  the  chronic  form  is  not. 

Treatment. — Not  satisfactory.  Inhalations,  counterirri- 
tation,  and  the  administration  of  stimulating  expectorants  or 
emetics.     Iodid  of  potassium  is  useful  in  the  chronic  form. 

CHRONIC  BRONCHITIS.1 

This  is  not  common  in  early  life,  but  may  be  seen  asso- 
ciated with  heart  disease,  emphysema,  interstitial  pneumonia, 
tuberculosis,  hereditary  syphilis,  and  following  the  acute  in- 
fections.    It  may  also  be  seen  in  malnutrition  and  rickets. 

Symptoms. — There  is  cough,  which  is  frequently  parox- 
ysmal and  is  liable  to  be  more  severe  at  night.  The  sputum 
may  be  scanty  or  abundant.  There  may  or  may  not  be 
coarse  rales.      Exacerbations  are  common. 

Diagnosis. — From  pertussis  by  the  course  of  the  dis- 
ease. A  marked  leukocytosis  is  suggestive  of  pertussis. 
From  tuberculosis  by  fever  and  loss  of  weight  with  progres- 

1  Allan,  "Persistent  Chronic  Bronchitis  in  Children,"  The  Practitioner, 
April,  1910,  p.  532. 


196  DISEASES  OF  INFANTS  AND  CHILDREN. 

sive  weakness.     A  positive  diagnosis  can  be  made  by  finding 
the  tubercle  bacilli  in  the  sputum. 

Treatment. — The  associated  disease  should  receive  atten- 
tion. Creosote  is  the  most  satisfactory  drug.  Cod-liver  oil 
is  of  great  service.  Terebene  and  iodid  of  potassium  may 
be  used.  If  the  cough  is  excessive  heroin  may  be  prescribed. 
A  change  of  climate  is  beneficial. 

BRONCHIECTASIS.1 

Definition. — A  dilatation  of  the  bronchial  tubes. 

Etiology. — This  is  seen  in  weak,  syphilitic,  or  rickety 
children  who  have  had  bronchitis.  It  often  follows  influenza. 
Lord  has  isolated  the  influenza  bacillus  in  cases  of  bronchi- 
ectasis. 

Pathology. — The  lung  presents  a  honeycombed  appear- 
ance throughout  part  or  even  all  of  the  lungs,  due  to  the 
dilated  bronchioles  and  small  cavities.  The  bronchi  are  sur- 
rounded by  a  small  zone  of  inflammation.  On  the  surface 
of  the  lung  there  are  small  vesicles  which  contain  air. 

Symptoms. — There  is  cough,  paroxysmal  in  character, 
and  relieved  by  the  expectoration  of  a  considerable  quantity 
of  foul-smelling  pus.  In  some  cases  the  sputum  is  swallowed, 
and  only  expelled  by  vomiting.  There  is  usually  some  de- 
formity of  the  chest,  and  often  clubbing  of  the  fingers. 
There  is  anemia  and  often  fever. 

The  physical  signs  consist  in  tubular  breath-sounds, 
together  with  rales,  which  vary  with  the  size  of  the  cavities 
and  the  amount  of  pus  in  them.  If  the  lesion  is  limited 
there  may  be  dulness. 

Diagnosis. — Principally  from  tuberculosis.  In  the 
cases  where  there  is  no  expectoration  this  may  be  very  diffi- 
cult. In  tuberculosis,  fever  is  more  constant,  the  disease 
progresses  more  rapidly,  and  there  may  be  involvement  of 
the  lymph-glands. 

Prognosis. — Bad.    Some  of  the  cases  live  for  many  years, 

■ 

1  Godlee  and  Fowler,  Diseases  of  the  Imngs.  Stanley  Box,  "  Bronchiec- 
tasis, Treatment  of,"  Practitioner^  June,  1906,  p.  839. 


THE  RESPIRATORY  SYSTEM.  197 

hut   almost   invariably  the   disease    sooner  or  later  causes 
death. 

Treatment. — Fresh  air,  good  hygiene  and  food,  tonics, 
especially  cod-liver  oil,  and  creosote  are  advised.  Locally 
inhalations  of  creosote,  eucalyptus,  or  sprays  of  iodoform 
emulsion  may  be  tried. 

NERVOUS    COUGH;    REFLEX  COUGH, 

These  terms  are  applied  to  cough  produced  by  disease  of 
other  organs  than  those  of  respiration.  It  may  be  caused  by 
adenoids,  elongated  uvula,  enlarged  mediastinal  glands  or 
abscess  in  the  posterior  mediastinum  (as  that  caused  by 
Pott's  disease),  heart  disease,  anemia,  and  general  nervous- 
ness. 

Symptoms. — The  cough  is  usually  worse  at  night,  and 
is  liable  to  be  paroxysmal  in  character,  especially  if  due  to 
intrathoracic  causes. 

Diagnosis. — This  is  possible  only  by  the  most  careful 
observation  and  examination. 

Treatment. — Treat  the  underlying  cause  when  found. 
To  relieve  the  cough  phenacetin  or  antipyrin,  combined  with 
sodium  bromid,  may  be  given  at  bedtime. 

ASTHMA.1 

This  is  a  term  applied  to  most  conditions  where  there  is 
dyspnea,  but  it  should  be  limited  to  the  spasmodic  attacks 
associated  with  catarrh  of  the  bronchi.  It  is  not  a  very 
common  disease  in  early  life,  but  may  be  seen  in  later  child- 
hood. 

Etiology. — It  may  be  hereditary  and  is  most  frequently 
seen  in  gouty  or  neurotic  families.  It  may  be  due  to  local 
causes,  as  rhinitis,  adenoids,  or  elongated  uvula.  The  pollen 
of  certain  plants  and  numerous  other  things  may  cause  it. 

Symptoms. — Adult  type. — There  are  wheezing  respira- 
tion, cough,  and  dyspnea.  Loud  rales  are  heard  on  ausculta- 
tion. The  attack  passes  oif  with  treatment  or  after  several 
1  La  Fetra,  Archives  of  Pediatrics,  December,  1904,  p.  904. 


198  DISEASES  OF  INFANTS  AND  CHILDREN. 

hours  without  treatment,  but  recurs  after  hours,  days,  or 
weeks.  Emphysema  may  result.  Attacks  simulating  capil- 
lary bronchitis  may  occur  in  infants,  but  lasting  only  a  few 
hours  or  a  day.  Some  children  get  spasmodic  dyspnea  with 
every  attack  of  catarrhal  bronchitis.  Hay  fever  is  rarely 
seen  before  puberty. 

Diagnosis.  — This  is,  as  a  rule,  easy.  Sometimes  the  dis- 
ease can  only  be  told  by  the  recurring  attacks. 

Prognosis. — If  due  to  a  removable  cause,  as  asthma,  the 
outlook  is  good.  The  infantile  forms  usually  have  a  favor- 
able outlook,  but  death  may  occasionally  result.  The  danger 
usually  is  that  the  disease  becomes  chronic. 

Treatment. — Examine  nose,  throat,  and  chest,  and  treat 
all  abnormalities  or  diseases  as  far  as  possible.  During  an 
attack  place  the  child  in  a  tent  filled  with  the  fumes  of  stra- 
monium leaves  and  niter  paper.  (Himrod's,  Kidder's,  or 
Kutnow?s  cures  are  convenient  mixtures  to  use.)  Emetics 
may  be  given  if  the  stomach  is  full.  To  prevent  recurrence 
full  doses  of  antipyrin  may  be  given.  A  change  to  another 
climate  is  best  where  the  disease  shows  a  tendency  to  become 
chronic.  Iodid  of  potassium  and  tonics  may  be  used  between 
the  attacks. 

PNEUMONIA.1 

This  is  one  of  the  most  frequent  diseases  of  infancy  and 
childhood,  and  is  often  a  cause  of  death.  It  is  an  inflam- 
mation of  the  lung.  There  are  two  principal  forms — broncho- 
pneumonia, also  called  catarrhal  or  lobular  pneumonia,  and 
lobar  or  croupous  pneumonia.  Other  forms  are  hypostatic 
and  chronic  bronchopneumonia.  Pneumonia  is  frequently 
complicated  with  pleurisy,  and  then  the  condition  is  called 
pleuropneumonia.  Pneumonia  may  also  be  due  to  tubercu- 
losis or  other  diseases.  In  a  general  way  the  diagnosis  of 
pneumonia  may  be  suspected  when  a  child  is  taken  suddenly 
ill  with  fever,  cough,  and  depression,  with  rapid  respiration, 
in  which  the  ratio  of  the  pulse  is  about  1  to  3,  and  if  added  to 

1  W.  P.  Northrup,  "  Pneumonia,  Cold  Fresh  Air  Treatment  in,"  Boston 
Medical  and  Surgical  Journal,  February,  1906,  p.  216. 


THE  RESPIRATORY  SYSTEM.  199 

this  there  is  flaring  of  the  nostrils,  a  change  from  the  or- 
dinary breathing,  which  is  first  inspiration,  then  expiration, 
then  a  pause,  to  what  might  be  called  pneumonic  breathing, 
which  is  inspiration  followed  by  a  pause,  then  expiration  fol- 
lowed by  a  grunt,  and  if  there  is  also  slight  rigidity  of  the 
neck  and  upper  extremities,  the  diagnosis  is  almost  certain, 
and  can  easily  be  confirmed  by  a  careful  examination  of  the 
chest. 

BRONCHOPNEUMONIA, 

This  is  seen  most  frequently  in  infancy. 

Etiology. — Somewhat  over  half  the  cases  occur  during 
the  first  year  and  one-third  more  during  the  second  year. 
After  the  fifth  year  it  is  very  rare.  The  primary  form  affects 
males  more  frequently  than  females  (5  :  4).  In  the  secondary 
form  the  sexes  are  affected  about  equally.  It  is  most  often 
met  with  in  the  weak,  the  sick,  poorly  nourished,  and  poorly 
housed.  It  is  common  in  asylums.  Over  half  the  cases  are 
secondary  to  other  diseases,  especially  to  measles,  pertussis, 
diphtheria,  and  ileocolitis.  Xo  one  organism  is  found  in  all 
cases.  Most  frequently  there  is  the  pneumococcus,  the 
streptococcus,  or  the  staphylococcus  aureus.  Other  organisms 
are  found  more  rarely.  There  are  frequently  two  or  more 
forms  of  bacteria  found  in  the  same  case.  The  secondary 
cases  are  often  due  to  streptococci,  and  the  areas  are  small 
and  separated.  Large  areas  of  consolidation  are  usually  due 
to  the  pneumococcus. 

Pathology. — The  disease  involves  the  smaller  bronchi- 
and  the  adjacent  air  cells.  The  walls. of  the  bronchi,  the  air 
cells,  and  the  interstitial  tissue  of  the  lung  are  infiltrated 
with  an  exudate,  and  the  bronchi  and 'air  spaces  are  filled 
with  it.  The  areas  of  consolidation  are  usually  small  and 
are  scattered  through  the  lung,  and  are  separated  by  patches 
of  normal  lung.  They  may  run  together,  however,  and  form 
areas  of  consolidation  of  considerable  size.  The  patches  vary 
in  size  from  less  than  a  millimeter  to  several  centimeters. 
The  disease  is  usually  bilateral,  but  in  about  one-tenth  of  the 
cases  one  lung  only  is    involved.     In  this  case  the  apices 


200  DISEASES  OF  INFANTS  AND   CHILDREN. 

(right)  are  most  frequently  affected.  As  a  general  rale  the 
left  lower  lobe  is  most  frequently  involved.  The  exudate 
consists  of  red  and  white  cells,  and  differs  from  the  exudate 
of  lobar  pneumonia  in  that  it  contains  numerous  epithelioid 
cells  and  very  little  fibrin.  In  some  cases  the  process  is  not 
unlike  the  lobar  pneumonia,  and  in  these  cases  the  fibrin  is 
more  abundant.  The  disease  runs  no  definite  course.  During 
the  first  clay  or  two  there  is  congestion  of  the  lungs,  but  after 
several  days  the  process  becomes  localized  in  certain  areas 
which  are  reddish  and  semisolid.  There  may  be  hemorrhages. 
After  a  few  more  days  there  is  more  complete  consolidation, 
and  the  lung  presents  a  mottled  red  and  gray  appearance 
which  turns  to  gray  almost  entirely  after  the  first  two  weeks. 
(The  bronchi  are  filled,  as  well  as  the  air  cells,  and  not  empty 
as  in  lobar  pneumonia.)  Sometimes  one  part  of  the  lung 
clears  up  and  another  becomes  affected.  There  is  compen- 
satory emphysema  over  the  unaffected  part  of  the  lungs.  The 
bronchial  lymph-glands  are  swollen.  Pleurisy  is  common  if 
the  disease  reaches  the  surface  of  the  lung.  Death  or  resolu- 
tion may  occur  at  any  time,  or  the  disease  may  last  for  weeks. 
Gangrene  and  abscess  or  empyema  may  follow. 

Symptoms. — Bronchopneumonia  has  no  regular  course. 
The  primary  form  may  come  on  suddenly  or  gradually,  while 
the  secondary  form  has  nearly  always  a  gradual  onset.  In 
most  cases  the  disease  starts  in  as  a  pneumonia,  but  some- 
times it  is  apparently  a  bronchitis  for  several  days  and  then 
changes  into  a  pneumonia.  In  other  cases  the  dominant 
symptoms  are  vomiting  and  diarrhea  and  the  real  disease  may 
be  overlooked.  The  pulse  is  rapid,  the  respiration  is  labored 
and  rapid,  the  child  is  depressed,  and  usually  has  an  appear- 
ance suggesting  pneumonia.  There  may  be  vomiting,  chill,  or 
convulsions,  at  times  there  are  intense  nervous  symptoms  at 
the  onset,  even  delirium,  and  later  coma.  The  disease  may  ter- 
minate at  any  time  either  in  death  or  by  getting  well.  Some 
cases  last  only  a  few  days  and  are  called  the  abortive  form. 
The  average  form  lasts  from  two  to  three  weeks,  and  the  pro- 
tracted form  from  one  to  four  months  and  occasionally  longer. 
The  very  protracted  cases  usually  die  from  exhaustion. 


THE  RESPIRATORY  SYSTEM. 


201 


The  temperature  is  extremely  irregular,  going  up  and 
down  without  apparent  reason.  In  vigorous  children  and  in 
severe  cases  the  tendency  is  to  be  high,  in  weak  depressed 
children  it  may  be  low,  and  some  cases  run  a  subnormal 
temperature. 

The  respirations  vary  from  40  to  60  and  sometimes  go  as 


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Fig.  55.— Temperature  chart  in  a  case  of  typical  bronchopneumonia  of  average 

severity. 

high  as  80  or  over.  The  amount  of  cough  varies  ;  in  some 
it  is  troublesome  and  painful  and  in  others  slight. 

The  pulse  is  rapid,  ranging  from  120  to  160  to  200. 
It  usually  grows  weaker  and  more  rapid  as  the  disease  pro- 
gresses, especially  in  unfavorable  cases. 

Cyanosis  is  a  common  symptom  and  comes  on  when  the  tem- 
perature is  high,  the  respiration  labored,  or  when  the  heart  flags. 


202  DISEASES  OF  INFANTS  AND  CHILDREN 

Nervous  symptoms  are  often  marked,  restlessness,  delirium, 
and  later,  apathy,  stupor,  and  even  coma.  Sometimes  symp- 
toms resembling  meningitis  are  seen.    Convulsions  may  occur. 

Pain  is  not  frequent  unless  the  pleura  is  involved,  but  the 
patients  are  usually  considerably  distressed. 

There  may  or  may  not  be  gastric  and  intestinal  disturb- 
ance. Flatulence  is  common  and  distressing  and,  in  weak 
children,  a  source  of  danger.  Diarrhea  is  not  infrequent, 
and  is  usually  due  to  intestinal  indigestion. 

There  is  albuminuria  in  most  cases  and  there  may  be  casts 
and  nephritis  in  some. 

Acute  Congestive  Form. — This  comes  on  suddenly,  with 
high  temperature,  often  a  convulsion,  rapid  breathing,  rapid 
pulse,  cyanosis,  and  intense  nervous  symptoms.  The  physi- 
cal signs  are  those  of  congestion.  The  child  may  die  or 
recover  almost  entirely  in  the  first  few  days,  or  the  disease 
may  change  into  the  ordinary  form. 

Capillary  Bronchitis. — This  is  essentially  a  bronchopneu- 
monia, although  cases  occur  in  which  the  lesions  are  nearly 
if  not  entirely  confined  to  the  bronchi,  especially  the  finer 
tubes.  There  is  irregular  fever,  cyanosis,  dyspnea,  rapid 
respiration,  and  troublesome  cough.  The  physical  signs  are 
those  of  bronchitis,  with  coarse  and  fine  rales  and  usually 
subcrepitant  rales.  The  breath  sounds  are  feeble  and  the 
percussion  notes  may  be  more  resonant  than  normal,  owing 
to  emphysema.  The  child  may  die  or  get  well  in  four  or 
five  days  or,  as  in  the  above,  it  may  change  to  the  usual  form. 

Protracted  Cases. — These  are  distressing,  the  symptoms 
and  signs  usually  decrease  somewhat  and  persist.  The  child 
gets  weaker  and  weaker,  and  usually  dies  from  exhaustion. 
Recovery  may  take  place  even  in  cases  apparently  almost 
hopeless.     Convalescence  is  always  slow. 

Secondary  Bronchopneumonia. — These  cases  are  like  the 
above  except  that  they  complicate  other  diseases,  usually 
measles,  diphtheria,  influenza,  whooping-cough,  and  gastro- 
enteric diseases.  The  signs,  symptoms,  and  course  are  about 
as  outlined  above,  except  that  the  secondary  cases  are  more 
liable  to  prove  fatal. 


THE  RESPIRATORY  SYSTEM.  203 

Physical  Signs. — Congestion. — There  is  lessened  breath- 
ing over  the  affected  area,  later,  tine  crackling  rales  ;  then 
higher  pitched  breathing,  and  over  the  remainder  of  the 
chest  often  loud  bronchial  rales.  A  common  error  is  to  place 
the  pneumonia  on  the  wrong  side  at  first,  owing  to  the 
louder  breathing  being  mistaken  for  the  diseased  area. 

Cases  with  Signs  of  Bronchitis. — There  may  be  only  signs 
of  bronchitis.  Fine  rales,  usually  moist,  and  usually  local- 
ized to  one  area  or  to  several,  sometimes  more  or  less  general. 
The  breath  sounds  are  usually  higher  in  pitch  over  the 
affected  area ;  coarser  rales  are  usually  heard  throughout  the 
chest.  The  diagnosis  in  these  cases  may  depend  more  on 
the  general  appearance  and  symptoms  than  the  signs. 

Small  Areas  of  Consolidation. — There  is  high-pitched, 
bronchovesicular  breathing,  crackling  rales,  and  the  breath 
sounds  are  transmitted  more  clearly.  There  is  little  or  no 
dulness,  and  the  respiration,  being  feeble,  may  lead  to  the 
same  mistake  mentioned  above. 

Consolidation. — There  is  some  dulness,  slight  increase  in 
fremitus,  bronchial  breathing,  fine  crackling  rales,  and  louder 
bronchial  rales. 

Complications. — These  are  numerous.  There  may  be 
acute  emphysema,  pleurisy,  abscess,  or  gangrene.  There  may 
be  meningitis,  endocarditis,  or  pericarditis,  gastro-enteritis, 
or  nephritis.  In  some  epidemics  there  seems  to  be  an  espe- 
cial tendency  to  some  one  complication. 

Prognosis. — This  is  bad  in  weak  or  young  infants.  After 
one  year  of  age  the  prognosis  is  better,  and  increases  with 
the  age  of  the  child.  The  disease  is  particularly  fatal  in  in- 
stitutions and  among  the  very  poor.  The  outlook  is  better 
in  breast  fed  than  in  bottle  fed.  The  outlook  is  unfavorable 
in  badly  nourished  children,  where  there  is  a  lack  of  fresh 
air,  when  the  chest  muscles  and  bones  are  weak,  when  the 
amount  of  lung  involved  is  large,  when  there  is  continuous 
high  fever,  when  there  is  cyanosis  and  cerebral  symptoms. 
Secondary  cases  are  more  fatal  than  primary  ones. 

Treatment. — The  child  should  be  kept  at  rest  and  in  the 
fresh  air,  either  out  of  doors  or  in  a  well- ventilated  room. 


204  DISEASES  OF  INFANTS  AND   CHILDREN. 

The  clothing  should  be  light,  and  there  should  not  be  any 
heavy  poultices  or  jackets  used,  as  they  embarrass  respiration. 
The  position  should  be  changed  from  time  to  time.  There 
should  be  quiet  about  the  child  and  no  visitors  or  unnecessary 
talking.  Sufficient  but  not  too  much  water  to  drink.  Care- 
ful feeding  is  imperative  (see  Feeding).  Nervous  symptoms 
and  high  temperature  are  both  best  relieved  by  cold  spong- 
ing, packs,  or  ice-bags.  Antipyrin  with  or  without  codein 
may  be  used  for  intense  nervousness,  excessive  cough,  or 
pain.  Codein,  heroin,  or  sodium  bromid  may  also  be  used 
for  excessive  cough.  The  fewer  drugs  given  the  better,  and 
never  give  expectorants,  they  do  no  good  and  upset  the 
stomach.  The  heart  should  be  stimulated  with  strychnin, 
alcohol,  strophanthus,  camphor,  or  atropin.  If  necessary, 
strychnin  or  Merck's  digitalin  may  be  given  hypodermatic- 
ally.  Aromatic  spirits  of  ammonia  by  mouth  or  adrenalin 
(1  to  3  minims  of  the  1  :  1000  solution)  injected  into  the 
muscles  is  useful  in  acute  collapse,  and  atropin  or  strychnin 
in  respiratory  failure.  Dyspnea  and  cyanosis  are  often  best 
relieved  by  a  mild  mustard  plaster  applied  to  the  entire  chest 
and  left  on  only  until  the  skin  reddens.  This  may  be  used 
every  three  or  four  hours  if  necessary,  and  if  used  with 
caution  may  be  continued  for  days.  The  chest  should  be 
greased  after  it  is  removed.  Camphorated  oil  may  be  used 
as  a  mild  counterirritant.  Inhalation  as  in  bronchitis.  In 
very  severe  cases  oxygen  inhalations  may  be  used.  Creosote 
or  guaiacol  carbonate  may  be  given  in  protracted  cases.  A 
change  of  climate  does  more  for  these  than  anything  else. 
The  bowels  should  be  kept  open  and  all  annoying  symptoms 
relieved.  The  more  comfortable  the  child  the  more  liable  he 
is  to  get  well. 

Diagnosis. — Bronchopneumonia  is  characterized  by  rales. 
Sudden  onset,  cough;  rapid  respiration,  and  high  fever  suggest 
pneumonia.  If  the  fever  remains  above  1 02  °  to  1 03  °  F.  for  over 
forty-eight  hours,  or  there  is  marked  cyanosis  or  prostration, 
the  diagnosis  is  almost  certain.  From  atelectasis  during  iirst 
few  months  of  life  by  the  subnormal  temperature.  The  two 
conditions  may  be  associated  and  diagnosis  be  impossible. 


THE  RESPIRATORY  SYSTEM. 


205 


Bronchopneurnoniob. 
Primary  or  secondary. 
<  toset  sudden  or  gradual. 
High  irregular  fever. 
Gradual  defervescence. 
Usually  involves  both  lungs. 
Marked     rales     throughout     entire 

course. 
Bronchial   breathing    may  or    may 

not  be  present. 
Dulness  rarely  marked. 
Slight  increase  in  fremitus. 
Resolution  slow. 
Relapse  common. 
Prognosis  bad. 


Lobar  pneumonia. 

Usually  primary. 
Onset  sudden. 
High  continuous  fever. 
Crisis  frequent — sixth  to  twelfth  day. 
Usually  only  one  lung. 
Rales  at  beginning  and  during  reso- 
lution only. 
Bronchial  breathing  marked. 

Dulness  marked  after  third  day. 
Fremitus  marked. 
Resolution  rapid. 
Relapse  rare. 
Prognosis  good. 


LOBAR  PNEUMONIA.1 
( Croupous  Pneumonia ;  Inflammation  of  the  Lungs ;  Lung  Fever.) 

Etiology. — This  is  usually  primary  aud  comes  on  after 
exposure  to  cold  aud  wet.  It  affects  the  healthy  as  often  as 
the  weak.  FrankePs  diplococcus  is  nearly  always  present. 
Lobar  pneumonia  is  the  common  form  of  pneumonia  after 
two  years  of  age. 

Pathology. — A  lobe  or  a  part  of  a  lobe  is  affected.  The 
left  base  is  the  most  frequent  location  ;  then  the  right  apex, 
right  base,  and  left  apex.  More  rarely  both  lungs  may  be 
attacked.  There  are  four  stages  :  Congestion,  red  hepatiza- 
tion, gray  hepatization,  and  resolution.  The  air  cells  are 
filled  with  an  exudate,  which  in  the  red  stage  is  composed  of 
fibrin,  red  and  white  blood  cells,  the  red  predominating.  In 
the  gray  stage  the  white  cells  are  most  numerous.  After  a 
week  or  ten  days  resolution  begins,  often  suddenly,  and  by 
the  end  of  another  week  the  lung  is  cleared  up.  The  smaller 
bronchi  are  also  filled  with  exudate,  but  the  larger  ones  rarely 
(massive  pneumon ia). 

Symptoms. — The  onset  is  sudden,  with  a  chill  or  a  con- 
vulsion.    The  face  is  flushed ;  there  are  high  fever,  rapid^ 

1  Morse,  Archives  of  Pediatrics,  September,  1904,  p.  641.  Coutts,  "  Oc- 
currence and  Treatment  of  Lobar  Pneumonia  in  Young  Ckildren,"  Edin- 
burgh Medical  Journal,  September,  1902. 


206 


DISEASES  OF  INFANTS  AND   CHILDREN. 


irregular  respiration,  and  a  dry,  hacking  cough.  Later  on 
delirium  may  be  present  or  even  coma.  Where  the  mental 
symptoms  predominate  the  disease  is  sometimes  called  cere- 
bral pneumonia.   The  temperature  rises  rapidly  to  103°— 105°, 


Urine 

Day  ot 
Disease 

Fio.  56.— Typical  temperature  chart  in  lobar  pneumonia  showing  crisis  on  the 

ninth  day. 

and  remains  high  until  resolution  begins,  when  it  usually  ends 
by  crisis.     It  may  end  by  lysis  in  some  cases. 

The  Physical  Signs. — Congestion. — The  breathing  over 
the  affected  area  is  diminished,  and  it  is  increased  over  the 


THE  RESPIRATORY  SYSTEM.  207 

remainder  of  the  lung.  Later,  as  the  exudate  fills  the  lung, 
there  are  fine  subcrepitant  rales. 

Consolidation. — There  are  lessened  mobility  of  the  chest 
over  the  affected  area,  increased  fremitus,  dulness,  bronchial 
breathing,  and  after  the  first  stage  few  or  no  rales  until  reso- 
lution begins. 

Resolution. — There  are  numerous  moist  rales,  the  breathing 
becomes  bronchovesicular,  and  the  dulness  and  fremitus 
diminish. 

Varieties. — A  central  pneumonia  may  be  confusing. 
The  area  is  surrounded  by  healthy  lung,  and  it  may  be  days 
before  the  consolidation  reaches  to  the  surface  of  the  lung. 
In  the  meantime  the  symptoms  of  pneumonia  are  present, 
but  no  physical  signs.  The  area  of  consolidation  may 
gradually  extend  from  one  place  to  another  (creeping  pneu- 
monia). After  a  typical  onset  the  patient  may  suddenly 
recover  after  two  or  three  days.  Either  a  creeping  or  ordinary 
pneumonia  may  last  two  or  three  weeks  (prolonged  pneu- 
monia) or  longer. 

Complications. — Pleurisy  is  most  common.  Dry 
pleurisy  is  present  in  nearly  every  case.  Pericarditis, 
meningitis,  otitis,  and  peritonitis  may  occur.  Gangrene  and 
abscess  are  rare. 

Diagnosis. — Any  disease  beginning  with  sudden  onset 
with  high  fever  may  be  mistaken  for  a  pneumonia.  Examine 
the  chest  in  every  case.  (See  Meningitis.)  Empyema  may 
be  mistaken  for  pneumonia  in  children.  (See  same.)  A 
puncture  settles  the  question. 

Prognosis. — Good.      About  4  per  cent,  of  all  cases  die.. 

Treatment. — Very  much  as  in  bronchopneumonia. 
Codein,  bromids,  or  antipyrin  or  phenacetin  may  be  used 
for  the  cough  and  nervousness.    Cold  pack  will  often  relieve  it. 

HYPOSTATIC  PNEUMONIA. 

This  is  a  term  applied  to  the  congestion  of  the  posterior 
part  of  the  lungs  when  a  child  lies  on  its  back  much  of  the 
time.     It  is  seen  as  a  complication  of  many  chronic  diseases. 


208  DISEASES  OF  INFANTS  AND   CHILDREN 

The  affected  part  of  the  lung  has  a  strip  of  very  dark  solid 
or  nearly  solid  lung,  which  is  dark  red  and  edematous-look- 
ing.  There  are  no  symptoms  and  no  physical  signs  beyond 
a  few  moist  rales  along  either  side  of  the  spine. 

Treatment  should  be  directed  toward  the  original  con- 
dition.   The  position  of  the  child  should  be  changed  frequently. 

PLEUROPNEUMONIA. 

This  is  a  lobar  pneumonia  with  an  exudate,  usually  of 
fibrin,  into  the  pleural  cavity.  The  symptoms  are  more 
intense  than  in  simple  pneumonia,  and  there  are  pleuritic 
friction  sounds  until  the  exudate  fills  the  pleural  cavity,  and 
then  the  physical  signs  of  the  pneumonia  are  somewhat 
lessened.  It  may  be  mistaken  for  empyema,  but  the  diag- 
nosis may  usually  be  made  by  puncture.  Sometimes  a  little 
pus  may  be  found  even  in  pleuropneumonia.  The  treatment 
is  the  same  as  for  uncomplicated  pneumonia. 

CHRONIC  INTERSTITIAL  PNEUMONIA. 
(Chronic  Bronchopneumonia*) 

This  is  a  chronic  inflammation  of  the  connective  tissue  of 
the  lung,  and  follows  tuberculosis  or  repeated  attacks  of 
bronchopneumonia.  The  bronchi  are  affected  and  are  usually 
dilated  (bronchiectasis). 

Pathology. — There  are  thick  bauds  of  connective  tissue 
running  through  affected  portions  of  the  lung  and  firm  adhe- 
sions to  the  pleura.  There  are  emphysema  and  enlargement 
of  the  bronchial  lymph  glands. 

Symptoms. — Following  a  pneumonia  there  is  a  little 
cough  and  dulness  with  bronchovesicular  breathing.  This 
lasts  months  or  years.  After  several  attacks  of  pneumonia 
the  disease  becomes  marked.  There  are  retraction  of  the  chest, 
increased  fremitus,  dulness,  feeble  respiratory  murmurs  or 
bronchial  breathing. 

Diagnosis. — Tuberculosis  is  diagnosed  on  finding  the 
tubercle  bacilli  or  by  exposure,  surroundings,  and  family 
history. 


THE  RESPIRATORY  SYSTEM.  209 

Prognosis. — This  is  poor.  Patient  usually  succumbs 
sooner  or  later.  Jn  the  most  favorable  cases  the  patient  is 
more  or  less  feeble  all  his  life. 

Treatment. — Change  of  climate  and  the  out-of-door  life, 
as  in  tuberculosis — cod-liver  oil  and  the  like. 

GANGRENE  OF  THE  LUNG.1 

This  is  rare,  but  occasionally  follows  bronchopneumonia? 
lobar  pneumonia,  empyema  or  tuberculosis,  especially  after 
measles  or  in  general  pyemia.  The  surface  of  the  lower 
lobes  is  most  frequently  affected.  The  areas  are  generally 
small,  but  may  involve  the  entire  lung. 

Symptoms. — The  majority  of  cases  are  not  recognized 
during  life,  as  death  takes  place  before  the  lungs  break 
down.  If  this  occurs  before  death  there  is  a  gangrenous 
odor,  pieces  of  the  lung  are  expectorated,  and  there  may  be 
hemorrhage.  In  all  cases  there  are  great  prostration  and 
severe  anemia. 

Prognosis. — Bad. 

Treatment. — Symptomatic  and  the  use  of  deodorizing 
inhalations.  Keep  the  child  in  the  open  air.  Surgical 
measures  are  sometimes  of  value. 

EMPHYSEMA. 
(Volumen  Auctum  Pulmonum.) 

This  is  due  to  overdistention  of  the  air  vesicles,  and  may 
be  caused  by  the  lung  doing  the  work  of  a  non-functionating 
part  (compensatory  emphysema),  as  in  tuberculosis,  pneu- 
monia, pleurisy,  and  the  like.  It  may  also  be  caused  by 
stenosis  of  the  larynx,  in  severe  coughing,  as  in  whooping- 
cough,  and  by  holding  the  breath. 

lesions. — The  connective  tissue  of  the  lung  is  stretched 
and  loses  part  of  its  contractility.  The  emphysema  may  affect 
a  part  or  the  whole  of  the  lung.  It  is  most  frequently  seen 
about  the  edges.  The  vesicles  may  rupture  and  the  air 
escape  into  the  connective  tissue,  causing  various-sized  blebs 
(interstitial  emphysema),  and  the  air  from  these  may  find  its 

1  Carr,  Archives  of  Pediatrics,  March,  1904,  p.  176. 
14 


210 


DISEASES  OF  INFANTS  AND  CHILDREN. 


way  into  the  mediastinum  and  thence  to  the  subcutaneous 
tissue  of  the  body.1  If  the  cause  be  removed  the  emphysema 
disappears  in  a  few  weeks  or  months. 

Symptoms. — There  is  increased  resonance,  and  in  marked 


Fig.  57.— Cutaneous  emphysema. 


cases  the  lung   boundaries   are   enlarged.      There   may  be 
expiratory  dyspnea. 

Treatment. — Treat  the  underlying  cause.    In  the  severe 
cases  from  coughing,  etc.,  rest  in  bed. 


PLEURISY. 

This  occurs  as  a  complication  of  the  various  lung  diseases, 
also  of  rheumatism,  and  occasionally  of  other  constitutional 
and  infectious  diseases,  and  there  may  be  a  primary  form 
from  exposure  to  cold  or  wet.  Tuberculosis  is  also  a  fre- 
quent cause.     There  may  or  may  not  be  an  effusion. 

Dry  Pleurisy. — This  occurs  as  a  complication  and  in 
older  children  may  be  primary. 

Lesions. — The  pleura  is  congested,  and  there  is  an  exuda- 
tion of  fibrin  on  the  surface  which  takes  off  the  gloss.  There 
may  be  large  amounts  of  fibrin  present.  If  it  become  chronic 
the  pleura  becomes  thickened. 

1  Pierson  and  Carr,  Archives  of  Pediatrics,  February,  1902,  p.  108. 


THE  RESPIRATORY  SYSTEM.  211 

Symptoms. — There  are  pain,  cough,  and  tenderness.  The 
diagnosis  rests  on  hearing  the  nibbing  friction-sound.  Re- 
covery takes  place  coincidently  with  that  of  the  original  dis- 
ease ;  but  some  cases  may  become  chronic.  The  primary 
cases  usually  recover  within  a  week. 

Treatment. — Strap  the  chest  or  use  counterirritations,  as 
iodin  or  mustard.     Anodyns  may  be  required. 

Pleurisy  with  Serous  Bffusion. — The  layers  of  the 
pleura  are  separated  by  an  effusion  of  serous  fluid.  This  may 
contain  bacteria. 

Symptoms. — This  may  come  on  suddenly  or  gradually. 
It  may  follow  a  dry  pleurisy  or  complicate  a  pneumonia  or 
tuberculosis.  If  it  follows  a  dry  pleurisy  the  pain  stops 
when  the  effusion  appears.  There  may  be  symptoms  refera- 
ble to  pressure  of  the  fluid,  such  as  displacement  of  the  heart, 
dyspnea,  and  cyanosis.  The  fluid  is  usually  absorbed.  If 
it  persists  general  weakness  and  anemia  follow. 

Physical  Signs  of  Fluid  in  the  Pleural  Cavity. — Mensuration. 
— The  affected  side  is  somewhat  larger  than  the  other  if  the 
effusion  be  large. 

Inspection. — Immobility  of  the  affected  side,  bulging  of 
the  intercostal  spaces,  and  there  may  be  displacement  of  the 
heart  (apex-beat).     Litten's  phenomenon  is  absent. 

Palpation. — Immobility  and  the  absence  of  vocal  fre- 
mitus. 

Percussion. — The  note  is  dull  or  flat.  The  position  of 
the  dulness  changes  with  the  position  of  the  patient.  The 
area  above  the  fluid  gives  a  tympanitic  note  (Skoda's  reso- 
nance). The  upper  border  of  the  effusion  makes  an  S- 
shaped  curve  (Ellis's  curve),  but  this  is  obliterated  in  very 
large  effusions. 

Auscultation. — In  children  there  is  usually  bronchial 
breathing,  and  consequently  the  diagnosis  of  pneumonia  is 
frequently  made.  There  are  no  rales,  but  friction-sounds 
may  be  heard  above  the  fluid  and  after  its  absorption.  The 
voice-sounds  are  usually  distinct  in  children,  and  near  the 
edge  of  the  fluid  sometimes  a  peculiar  bleating  quality  is 
added  (egophony). 


212  DISEASES  OF  INFANTS  AND   CHILDREN. 

Diagnosis. — From  pneumonia  by  the  absence  of  change  on 
changing  the  position  of  the  patient,  absence  of  Ellis's  curve, 
and  the  presence  of  rales.  From  empyema  by  puncture. 
This  should  be  done  whenever  fluid  is  suspected. 

Prognosis. — This  is  good,  as  a  rule. 

Treatment. — This  is  largely  symptomatic.  Rest,  careful 
feeding,  anodyns  as  required,  and  counterirritation  by  iodin 
or  mustard.  If  the  effusion  be  large,  aspirate.  If  absorp- 
tion be  prolonged,  give  iodid  of  potassium.  During  conva- 
lescence keep  in  the  open  air  and  manage  as  in  a  case  of 
tuberculosis. 

EMPYEMA.1 

Under  three  years  of  age  a  pleural  effusion  is  in  almost 
every  instance  purulent.  This  usually  follows  a  pneumonia, 
occasionally  one  of  the  infectious  diseases,  or  suppuration 
elsewhere.     In  later  childhood  it  may  be  tuberculous. 

Pathology. — The  pleural  cavity  is  filled  with  pus  and 
the  lung — and  often  the  heart — displaced.  The  pneumococ- 
cus,  streptococcus  pyogenes,  staphylococcus  pyogenes  aureus, 
or  the  tubercle  bacillus  may  be  found. 

Symptoms. — Very  much  as  in  serous  effusion.  There 
are  dyspnea,  cough,  and  fever,  which  is  usually  high  and 
irregular,  but  which  may  be  moderate.  There  is  a  leuko- 
cytosis. Seen  later,  there  is  always  profound  anemia  and 
prostration  with  emaciation.  There  is  albuminuria,  and  fre- 
quently in  the  chronic  cases  clubbing  of  the  ends  of  the  fingers. 
The  physical  signs  are  the  same  as  in  serous  effusion. 

Diagnosis. — By  puncture.  Pus  may  not  always  be 
found  the  first  time. 

Prognosis. — In  weak  and  very  young  children,  or  if  seen 
late,  the  prognosis  is  bad.  The  cases  where  the  pneumococ- 
cus  is  found  are  the  most  favorable.  The  presence  of  strep- 
tococci and  staphylococci  is  always  serious.  The  tubercu- 
lous cases  have  the  same  prognosis  as  tuberculosis  of  the 
lungs. 

1  Morse,  American  Medicine,  vol.  vii.,  p.  430.   William  Broadbent,  "  Em- 
pyema, Interlobar,"  Practitioner,  February,  1905,  p.  145. 


THE  RESPIRA  TOR  Y  SYSTEM.  2 1  3 

Treatment. — Open  the  chest  by  incision  and  secure  free 
drainage.  Under  two  years  of  age  a  longer  drainage-tube, 
which  will  syphon  ont  pns  gradually,  is  advisable.1  In  older 
children  a  rib  may  be  resected  if  necessary.  During  conva- 
lescence it  is  important  to  see  that  the  lung  is  expanded  by 
deep  respiration.  Blowing  bubbles  and  the  like  are  recom- 
mended. 

1  Holt,  American  Medicine,  June,  1913,  p.  381. 


214 


DISEASES  OF  INFANTS  AND  CHILDREN. 


HEART  AND  CIRCULATION  IN  INFANCY  AND 

CHILDHOOD. 

At  birth  the  circulation  through  the  umbilical  vessels  and 
the  ductus  venosus  and  the  ductus  arteriosus  stops.  The 
circulation  through  the  foramen  ovale  ceases  at  birth'  or 
shortly  afterward.  The  umbilical  vessels  atrophy  and  be- 
come mere  fibrous  cords. 

Pulse. — The  pulse-rate  is  very  easily  disturbed  during 
childhood,  and  varies  greatly  when  the  child  is  awake.  Holt 
gives  the  following  pulse-rates  during  sleep  : 

Six  to  twelve  months 105-115 

Two  to  six  years .    90-105 

Seven  to  ten  years 80-  90 

Eleven  to  fourteen  years 75-  85 

Apex-beat. — In  infants  this  is  higher  and  further  to  the 
left  than  in  adults.     It  is  in  the  fourth  space,  and  later  in 


Fig.  58.— Diagram  of  precardial  dulness  in  childhood  (Whitney). 

childhood  a  little  lower.     It  lies  in  the  mammillary  line,  or 
a  little  outside  of  it  in  infants,  and  as  the  child  grows  older 


HEART  AND  CIRCULATION.  215 

gradually  moves  inward  and  downward,  until  by  the  thir- 
teenth year  it  is  in  the  fifth  space,  just  inside  the  mammillary 
line.  The  apex-beat  may  be  difficult  to  see,  but  can  usually 
be  easily  felt. 

Both  relative  and  absolute  heart  dulness  are  relatively 
larger  in  childhood.  The  absolute  heart  dulness  is  a  trian- 
gular area  with  the  hypothenuse  running  from  the  third 
costal  cartilage  a  short  distance  from  the  left  border  of  the 
sternum  to  the  fourth  rib  somewhat  inside  the  mammillary 
line.  The  left  border  of  the  sternum  and  the  lower  border 
of  the  fourth  rib  are  the  other  two  sides  of  the  triangle.  As 
the  child  grows  the  area  of  dulness  changes  its  position  some- 
what, the  lower  border  being  lower  and  the  left  limit  extend- 
ing about  to  the  apex -beat. 

The  heart-beat  is  so  rapid  that  it  is  difficult  to  determine 
exactly  changes  in  the  sounds  of  the  infant's  heart.  The 
first  sound  is  loudest  at  the  apex,  and  is  heard  with  consid- 
erably lessened  intensity  over  the  lower  end  of  the  sternum. 
Reduplication,  due  to  the  valves  not  closing  in  perfect  time, 
is  very  common  in  children,  and  may  be  caused  by  excite- 
ment.    It  has  no  especial  significance  in  children. 

THE  HEART  IN  OLDER  CHILDREN. 

The  following  points  should  be  borne  in  mind  considering 
the  heart  in  later  childhood.  Mistakes  in  diagnosis  are 
common  at  this  age  by  inexperienced  observers,  owing  to  the 
fact  that  the  cardiac  area  is  very  large  and  one  frequently 
hears  accidental  murmurs.  The  most  reliable  method  of 
outlining  the  heart  in  the  child  is  to  percuss  for  the  absolute 
cardiac  dulness.  There  are  considerable  normal  variations 
of  this,  but  the  average  area  will  be  found  to  extend  to  the 
third  rib  above,  to  the  apex  beat  below  aud  to  the  left ;  and 
to  the  right  the  area  should  be  found  to  varv  according  to 
the  character  of  percussion  used.  With  ordinary  percussion 
the  heart  dulness  will  be  found  to  extend,  in  most  instances, 
to  the  right  border  of  the  sternum  or  even  slightlv  bevond 
it ;  while  with  light  percussion  the  dulness  extends  only  to 


216  DISEASES  OF  INFANTS  AND   CHILDREN. 

the  middle  of  the  sternum,  or  perhaps  more  frequently  to  the 
left  border  of  the  sternum.  The  apex  beat  is  usually  found 
in  the  fifth  space  just  inside  the  nipple  line,  although  it  may 
be  found  in  the  nipple  line  or  slightly  beyond  it.  If  the 
child  is  placed  in  a  recumbent  position  there  may  be  slight 
changes  in  the  heart  area,  chief  of  which  consists  in  a  fre- 
quent moving  upward  of  the  dulness  a  short  distance  and  a 
diminution  of  the  dulness  to  the  right. 

The  intensity  of  the  sounds  at  this  age  varies  considerably, 
but,  as  a  rule,  the  pulmonic  sound  at  the  base  is  louder,  or  at 
least  as  loud  as  the  aortic  sound,  both  in  the  erect  position 
and  when  lying  down.  The  first  sound  at  the  apex  beat  is 
almost  invariably  louder  than  the  second. 

Accidental  murmurs  are  very  frequent  at  this  age,  and 
there  has  been  considerable  discussion  both  as  to  the  cause 
and  to  the  value  of  diagnosis  of  these  murmurs.  The  chief 
point  is  to  distinguish  the  accidental  from  an  organic  murmur, 
and  this  can  usually  be  done  by  considering  the  following 
points  :  Accidental  murmurs  are  almost  invariably  systolic 
at  times.  They  are  most  frequently  heard  at  the  base  of 
the  heart,  but  may  be  heard  at  times  over  almost  any  area. 
They  vary  in  character,  both  as  to  intensity  and  as  to 
the  point  at  which  they  may  be  best  heard.  One  time  the 
murmur  may  be  heard  over  the  base  and  over  the  apex 
as  well,  and  at  other  times  only  over  the  base,  or  vice  versa. 
They  are  exceedingly  inconstant,  as  they  may  be  present  at 
one  time  and  absent  at  another.  They  frequently  change  on 
varying  the  position,  usually,  although  not  always,  becoming 
more  intense  when  the  child  is  placed  on  the  left  side.  They 
also  frequently  vary  with  the  respiratory  movements,  being 
heard  rather  better  during  expiration  than  during  inspiration, 
and  sometimes  they  may  be  made  to  vary  by  pressure  made 
on  the  abdomen.  The  presence  or  absence  of  gas  in  the 
stomach  may  also  influence  these  sounds.  The  organic 
murmur  is  more  steady  in  its  character  and  changes  but 
little  in  position,  and  varies  but  little  from  time  to  time. 
The  inorganic  murmur  is  unaccompanied  by  changes  in  the 
size  of  the  heart. 


HEART  AND   CIRCULATION. 


217 


CONGENITAL  HEART  DISEASE.1 

Congenital  heart  disease  is  cine  to  malformation  from  im- 
perfect  development,  changes  as  the  result  of  fetal  endo- 
carditis, or  the  persistence  of  fetal  conditions,  as  a  patent 
foramen  ovale. 

Defects  in  the  septa,  abnormalities  in  the  vessels,  or  stenosis 
or  insufficiency  of  any  opening  may  be  present.  The  most 
common  are  the  following  in   the  order  of  their  frequency  : 


Fig.  59.— Clubbing  of  fingers  in  congenital  heart  disease. 

Defect  of  the  ventricular  septum,  defect  in  the  auricular 
septum  or  patent  foramen  ovale,  pulmonic  stenosis,  patent 
ductus  arteriosus,  abnormalities  in  the  origin  of  the  vessels, 
and  pulmonic  insufficiency.  The  other  forms,  while  met  with, 
are  rare.  Two  or  more  lesions  are  frequently  associated. 
Pulmonic  stenosis  with  septum  defects  is  the  most  frequent. 

1  Morse,  Archives  of  Pediatrics,   October,  1901,  p.  744.     F.  J.  Poynton, 
"  Heart  Disease,  Congenital,"  British  Medical  Journal,  June  23, 1906,  p!  145S. 


218  DISEASES  OF  INFANTS  AND  CHILDREN. 

Patent  foramen  ovale  while  common  has  but  little  clinical 
'significance. 

Symptoms. — These  are  usually  noted  soon  after  birth, 
but  sometimes  not  until  later  life,  even  after  puberty.  Cyano- 
sis is  the  most  constant,  and  the  "  blue  babies  "  of  the  laity 
are  usually  cases  of  congenital  heart  disease.  The  number 
of  the  red  blood-cells  is  increased  in  these  cases.  Enlarge- 
ment of  the  right  heart  and  loud  systolic  murmurs  heard  at 
base  are  frequent.  There  are  clubbing  of  the  fingers  and 
sometimes  hemorrhages,  especially  from  the  nose  or  lungs, 
and  dropsy.     Dyspnea  is  present  in  some  cases. 

Diagnosis. — From  acquired  heart  disease  by  the  cyano- 
sis, the  clubbed  fingers,  the  enlargement  of  the  right  heart, 
loud  systolic  murmur  at  the  base  of  the  heart,  and  a  very 
young  patient  with  no  history  of  rheumatism. 

From  Hemic  Murmurs. — This  may  be  made  if  the  above 
symptoms  are  present ;  but  if  they  are  absent  and  only  the 
loud  murmur  heard  at  the  base  be  present,  this  question  can 
only  be  decided  by  careful  watching. 

As  to  the  Lesion. — This  is  difficult  or  impossible.  Holt 
gives  the  following  useful  points  based  on  a  study  of  225 
cases  : 

Systolic  Murmur  at  the  Base  with  Cyanosis.  — Eighty  per 
cent,  of  these  are  pulmonary  stenosis,  frequently  with  an  asso- 
ciated lesion ;  twenty  per  cent,  complicated  cases  of  various 
kinds. 

Systolic  Murmur,  no  Cyanosis. — Either  a  defect  in  the 
ventricular  septum,  tricuspid  regurgitation,  or  stenosis  of  the 
aorta. 

Systolic  Murmur  at  the  Apex  with  Cyanosis. — Complex 
lesions. 

Cyanosis,  but  No  Murmurs. — Pulmonary  atresia  or  trans- 
position or  irregular  origin  of  the  great  vessels. 

Diastolic  Murmur. — Pulmonary  insufficiency. 

Absence  of  Both  Cyanosis  and  Murmurs. — Atresia  of  the 
aorta  or  septum  defects. 

Presystolic  Murmur. — This  was  noted  in  1  case  of  patent 
foramen  ovale. 


HEART  AND   CIRCULATION.  219 

Prognosis. — Holt  gives  the  following  figures  :  30  per 
cent,  die  before  the  end  of  the  second  month  ;  60  per  cent, 
before  five  years;  16  per  cent,  live  to  reach  sixteen  years 
of  age;  8  per  cent,  live  to  be  over  thirty  years  of  age. 
The  general  condition  is  a  better  guide  to  what  the  case  is 
doing  than  cyanosis  or  murmurs. 

Treatment. — Symptomatic.  Nothing  influences  the 
lesion. 

PERICARDITIS. 

Definition. — Inflammation  of  the  pericardium.  This 
is  rare  in  infancy.  It  is  seen  oftener  in  later  childhood, 
especially  in  boys. 

Etiology. — Pericarditis  is  secondary  to  rheumatism  or 
to  an  infectious  disease,  as  pneumonia,  scarlet  fever,  tubercu- 
losis, or  it  may  be  caused  by  pyemia,  extension  from  an 
adjacent  pleurisy,  or  from  injury. 

Pathology. — Fibrinous  or  Dry  Pericarditis. — There  is  an 
exudate  of  fibrin,  covering  part  or  all  of  the  pericardium. 
Adhesions  between  visceral  and  parietal  layers  of  the  peri- 
cardium are  frequent. 

Serofibrinous  Pericarditis  or  Pericarditis  with  Effusion. — 
Some  fibrin  covers  the  pericardium,  which  gives  it  a  shaggy 
appearance.  There  is  an  effusion  of  a  serous  fluid,  which  is 
absorbed  if  cure  results.     Adhesions  are  a  frequent  sequela. 

Purulent  Pericarditis.1 — The  pericardium  contains  pus. 

External  Pericarditis. — Inflammation  of  the  outside  of  the 
pericardium,  usually  from  extension  of  pleurisy,  pneumonia, 
or  tuberculosis. 

Symptoms. — These  are  obscure  and  the  disease  is  fre- 
quently overlooked,  especially  as  the  disease  is  usually  sec- 
ondary. Palpitation  of  the  heart  with  feeble,  irregular  pulse, 
precordial  pain,  and  dyspnea  are  the  most  frequent.  There 
may  be  cyanosis. 

Physical  Signs. — Dry  Pericarditis. — A  to-and-fro  fric- 
tion-rub, consonant  with  heart  beat,  not  transmitted,  and  usu- 
ally- heard  at  the  base ;   if  the  heart  is  very  rapid,  this  may 

1  Batten,  Still,  Pediatrics,  October,  1901,  pp.  328,  332. 


220  DISEASES  OF  INFANTS  AND  CHILDREN. 

be  heard  as  a  sort  of  hum.  This  frequently  is  the  first  stage 
of  the  following  : 

Serofibrinous  Pericarditis. — Inspection. — Bulging  of  the  pre- 
cordiura  with  obliteration  of  the  intercostal  spaces  over  it. 

Palpation. — Friction-rub  may  sometimes  be  felt.  Apex- 
beat  feeble  or  absent. 

Percussion. — A  large  area  of  heart  dulness.  Dulness  in 
the  shape  of  two  triangles  joined  together  in  the  midsternal 


Fig.  60.— Pericarditis  with  effusion,  showing  area  of  dulness. 

line,  having  a  common  base  about  the  fifth  rib,  the  dulness 
merging  into  the  liver  dulness  below  on  the  right  and  into 
the  stomach  tympany  on  the  left.  The  right  triangle  is 
smaller  than  the  left,  with  its  apex  about  the  upper  border 
of  the  fourth  rib.  (This  varies.)  There  may  be  an  area  of 
dulness  in  the  left  infrascapular  region. 

Auscultation. — Often  a  friction-rub,  to  be  elicited  by  changes 
in  the  position  of  the  patient.     If  the  effusion  is  large  there 


HEART  AND  CIRCULATION.  221 

will  be  no  rub.  Endocardial  murmurs  may  also  be  heard. 
The  heart  sounds  may  be  distant  and  indistinct. 

Purulent  Pericarditis. — As  above,  with  the  addition  of 
chills,  sweats,  irregular  fever.  Marked  leukocytosis  is  pres- 
ent.    There  may  sometimes  be  edema  of  the  precordium. 

Diagnosis. — Acute  Endocarditis. — This  and  pericarditis 
are  so  rare  in  infants  under  two  years  that  they  need  not  be 
considered.  In  older  children,  as  in  adults,  the  endocarditis 
is  accompanied  by  a  softer  murmur,  heart  beat  at  the  apex 
and  transmitted  to  the  axilla  and  back. 

Dilatation  of  the  Heart. — This  is  seen  late  in  uncompen- 
sated valve  lesions,  and  in  these  cases  the  diagnosis  is  easy. 
The  milder  grades,  seen  after  infectious  diseases,  are  often 
puzzling. 

Hypertrophy  of  the  Heart. — The  heart  is  enlarged  down- 
wards, the  apex  beat  is  marked,  and  the  dulness  does  not 
extend  beyond  the  apex  beat. 

Pleuritic  Effusion. — This  is  difficult.  The  two  may  be 
associated  and  diagnosis  impossible.  Dulness  over  the  left 
front  of  the  chest,  with  weak  heart  sounds  and  apex  beat  in 
normal  position,  suggests  pericarditis. 

Prognosis. — As  regards  life  the  outlook  of  rheumatic 
cases  is  good,  after  infectious  diseases  bad.  The  remote  effects 
of  all  cases  are  serious. 

Treatment. — Absolute  rest.  Milk  diet.  Counterirri- 
tation  or  ice  bao;  over  heart.  Antirheumatic  treatment  where 
indicated.  Opiates  for  pain.  Stimulants,  alcohol,  strychnia, 
Merck's  digitaliu  if  needed.  If  effusion  be  large,  aspiration 
may  be  considered,  but  as  yet  the  results  are  unsatisfactory. 

OTHER  PERICARDIAL  LESIONS. 

Hydropericardium. — An  increase  in  the  serous  fluid  in 
the  pericardium  may  be  due  to  other  causes  than  inflamma- 
tion, as  in  general  dropsy  due  to  nephritis,  heart  disease,  or 
anemia. 

Hemopericardium. — An  effusion  of  blood  into  the 
pericardium.  Very  rare  in  children  and  practically  always 
traumatic,  but  it  may  occur  in  purpura  and  hemophilia. 


222  DISEASES  OF  INFANTS  AND  CHILDREN. 

Pneumopericardium. — Air  in  the  pericardium  is  very 
rare.  It  may  come  from  rupture  into  the  pericardium  of  a 
pyopneumothorax  or  a  tuberculous  cavity. 

CHRONIC  PERICARDITIS  WITH  ADHESIONS. 

This  follows  acute  pericarditis  and  is  usually  accompanied 
by  myocarditis,  hypertrophy,  or  dilatation  of  the  heart.  It 
may  not  cause  symptoms,  or  those  of  heart  failure  may  be 
present. 

Physical  Signs. — Inspection. — Bulging  of  the  chest  over 
the  heart.  Apex  beat  feeble  or  absent.  Systolic  retraction 
of  intercostal  spaces  near  apex  beat.  There  is  often  systolic 
retraction  in  the  tenth  or  eleventh  spaces  in  the  back,  usually 
to  the  left,  sometimes  to  the  right  (Broadbent's  sign).  Diastolic 
collapse  of  the  veins  in  the  neck. 

Percussion. — Increase  in  dulness  in  all  directions.  Apex 
beat  and  dulness  unchanged  by  inspiration  or  change  in  posi- 
tion. 

Auscultation. — There  may  be  endocardial  murmurs. 

Pulsus  paradoxus,  the  pulse  being  more  feeble  during 
inspiration,  is  frequently  present. 

There  may  be  enlargement  of  the  liver  with  ascites.  Edema, 
cyanosis,  and  dyspnea  may  be  present. 

Treatment. — Symptomatic. 

ENDOCARDITIS. 
Acute  Endocarditis. 

Definition. — An  inflammation  of  the  endocardium.  Fetal 
endocarditis  is  nearly  always  right-sided,  and  may  cause 
congenital  malformations.  From  birth  up  to  three  years  of 
age  the  disease  is  almost  unknown  ;  after  that  it  is  not  infre- 
quent. 

Etiology.1 — Rheumatism  is  the  most  frequent  cause.  It 
may  be  the  first  manifestation  of  that  disease.  It  is  often 
associated  with  chorea.  Any  infectious  disease  may  be  the 
cause  of  endocarditis. 

1  Blum,  Archives  of  Pediatrics,  May,  1903,  p.  341.  Sappington  and  Kau, 
"  Pericardium,  Adherent,"  Archives  of  Pediatrics,  1906,  p.  816. 


HEART  AND   CIRCULATION.  223 

Pathology. — The  inflammation  usually  affects  the  mitral 
valve,  the  aortic  more  rarely,  and  the  right  side  of  the  heart 
almost  never.  The  valve  becomes  infiltrated  with  an  inflam- 
matory exudate,  and  the  fixed  connective  tissue  cells  prolif- 
erate, causing  a  collection  of  small  round  cells.  On  the 
inflamed  area  fibrin  is  deposited,  which  results  in  small  excres- 
cences or  vegetations.  These,  or  the  swelling  of  the  valve, 
may  cause  leakage.  Contraction  of  the  chordae,  tendinse,  or 
deformity  of  the  valve  may  follow  and  cause  chronic  insuf- 
ficiency.    Ulceration  may  occur  in  ■  malignant  endocarditis. 

Symptoms. — There  are  fever,  restlessness,  prostration, 
and  frequently  some  dyspnea.  The  heart's  action  is  more 
rapid  and  vigorous.  The  physical  signs  may  not  be  present 
for  several  days,  and  are  often  overlooked  if  the  heart  be  not 
examined  regularly.  There  is  slight  enlargement  of  the  heart 
dulness  due  to  dilatation.  There  is  a  soft  blowing,  systolic 
murmur,  heard  best  over  the  apex  and  transmitted  to  the 
axilla.  There  may  be  a  thrill,  and  the  second  pulmonic  sound 
is  sometimes  accentuated. 

Symptoms  of  rheumatism,  chorea,  or  some  infectious  dis- 
ease are  frequently  present. 

If  there  be  marked  insufficiency  there  are  dyspnea,  cyanosis, 
and  edema.  These  cases  may  prove  fatal.  The  average  case 
recovers,  but  recurrences  are  frequent  and  chronic  heart 
lesions  often  result. 

Diagnosis. — Hemic  or  functional  murmurs  are  heard 
best  at  the  base,  and  are  not  transmitted.  They  are  usually 
inconstant. 

Pericarditis. — There  is  a  friction-rub  or  signs  of  pericardial 
effusion. 

Prognosis. — The  majority  of  the  cases  recover.  See 
above. 

Treatment. — The  child  should  be  kept  in  bed,  and  as 
quiet  as  possible.  For  pain  and  increased  heart  action  the 
use  of  the  ice-bag  is  best.  It  may  be  used  continuously  or 
intermittently.  Occasionally  a  hot-water  ba^  may  be  used, 
but  is  less  efficient.  In  rheumatic  cases  sodium  salicylate 
may  be  used,  and  aspirin  is  useful  where  there  is  much  pain 


224  DISEASES  OF  INFANTS  AND  CHILDREN. 

in  cases  from  all  causes.  Codein  in  sufficient  doses  is  best 
for  restlessness,  or  sodium  bromid  may  be  used.  Excessive 
heart  action  is  often  difficult  to  manage.  It  may  be  con- 
trolled by  strophantkus  or  codein,  sometimes  by  aconite,  and 
sometimes  by  atropin. 

These  cases  are  usually  difficult  to  feed.  The  food  should 
be  concentrated,  easy  of  digestion,  and  sufficient  time  allowed 
between  meals. 

During  convalescence  iron  is  of  benefit. 

MALIGNANT    OR    ULCERATIVE    ENDOCARDITIS.1 

Definitions. — Inflammation  and  ulceration  of  the  valves 
or  other  heart  structures. 

Etiology. — Usually  occurs  in  older  children,  in  those 
who  already  have  a  valvular  lesion,  and  is  generally  secondary 
to  rheumatism,  meningitis,  or  pneumonia. 

I^esions. — There  are  vegetations  which  may  become  de- 
tached and  cause  emboli.  The  ulceration  is  the  essential 
lesion. 

Streptococci,  staphylococci,  or  pneumococci  are  usually 
present. 

Symptoms. — There  is  great  prostration  with  irregular 
fever,  chills,  sweats,  delirium,  or  coma.  A  petechial  eruption 
is  common.  The  emboli  may  cause  symptoms  of  pneumonia, 
paralysis,  bloody  urine  and  the  like.  Heart  murmurs  are 
generally  present. 

Diagnosis. — It  may  be  mistaken  for  meningitis  or 
malaria. 

Pr  ogno  sis .  — Fatal . 

Treatment. — Symptomatic. 

CHRONIC  VALVULAR  DISEASE. 

Excluding  congenital  malformations,  chronic  valvular  dis- 
ease in  children  may  be  said  to  be  due  to  changes  caused  by 
endocarditis. 

1  Osier,  "  Gulstonian  Lectures,"  British  Medical  Journal,  March,  1885,  p. 
467. 


HEART  AND  CIRCULATION.  225 

Etiology. — There  may  be  either  insufficiency  or  stenosis, 
or  both.  One  or  more  valves  may  be  affected.  Insufficiency  is 
caused  by  imperfect  closure  of  the  valve,  due  to  thickening  or 
contraction  of  the  valve,  or  to  shortening  of  the  chorda?  ten- 
ding. Stenosis  is  due  to  thickening,  calcareous  deposits,  or  ad- 
hesions. Mitral  disease  is  the  most  frequent,  associated  mitral 
and  aortic  next,  and  aortic  disease  the  most  common  of  all. 

When  there  is  valvular  disease  the  heart  hypertrophies  in 
order  to  do  the  extra  work  caused  by  the  lesion.  In  some 
dilatation  occurs.  As  soon  as  this  becomes  marked  the  heart 
is  no  longer  able  to  pump  the  blood  through  the  body  and 
circulatory  disturbances  result.  This  is  called  broken  com- 
pensation. The  other  lesions  are  due  to  venous  obstruction 
and  consist  of  congestion  of  the  lung,  chronic  bronchitis,  and 
chronic  pneumonia  when  the  pulmonary  veins  are  affected, 
and  to  congestion  of  the  liver,  spleen,  kidneys,  and  later 
dropsy,  when  the  systemic  veins  are  affected. 

Symptoms. — Stage  of  Compensation. — This  may  con- 
tinue for  a  short  or  a  long  time.  There  is  shortness  of  breath 
on  exertion,  and  occasionally  headache,  pain  over  the  heart, 
palpitation,  and  other  variable  symptoms. 

Stage  of  Broken  Compensation. — This  may  be  brought  on 
by  the  heart  having  hypertrophied  to  the  limit  and  dilatation 
taking  place,  or  it  may  be  hastened  by  overexertion,  weaken- 
ing diseases,  or  other  attacks  of  endocarditis.  There  are 
numerous  symptoms.  Among  the  most  marked  are  the 
dyspnea,  cyanosis,  and  edema.  There  are  cough,  enlarged 
liver  and  spleen,  albuminuria,  clubbing  of  the  fingers,  head- 
ache, sleeplessness,  bad  dreams,  anxiety,  and  often  hallucina- 
tions of  sight,  especially  at  night. 

Varieties. — Mitral  Insufficiency  (Mitral  Regurgitation). — 
This  is  leakage  at  the  mitral  orifice,  due  to  imperfect  closure  of 
the  valve.  It  causes  hypertrophy  of  the  left  ventricle  and  en- 
largement of  the  right  auricle ;  then  of  the  right  side  of  the 
heart.  Later  on  tricuspid  insufficiency  is  caused ;  then  dila- 
tation becomes  marked. 

Inspection. — The  apex  beat  is  displaced  downward,  and  es- 
pecially to  the  left.    There  is  pericardial  bulging  in  some  cases. 

15 


226  DISEASES  OF  INFANTS  AND  CHILDREN. 

Per cu ssi 077. — There  is  an  enlarged  area  of  dulness  particu- 
larly to  the  left  and  downward ;  later  on  to  the  right  of  the 
sternum  and  downward. 

Auscultation. — There  is  a  systolic  murmur,  heard  best  at 
the  apex  and  transmitted  to  the  axilla  and  to  the  back  about 
the  angle  of  the  left  scapula.  There  is  accentuation  of  the 
second  pulmonic  sound. 

Pulse. — Full  and  strong. 

Stage  of  Dilatation. — Apex  beat  becomes  weak,  diffuse, 
and  undulatorv.  The  dulness  becomes  enlarged,  and  is 
nearly  square,  losing  the  distinct  transverseness  of  the  earlier 
stage.  Heart  sounds  feeble  and  sometimes  not  heard  at  all. 
Tbe  pulse  becomes  weak  and  irregular. 

Mitral  Stenosis. — This  is  an  obstruction  at  the  mitral  orifice, 
due  to  thickening  or  adhesions  of  the  valve.  It  is  usually 
associated  wTith  mitral  insufficiency,  but  may  occur  alone. 
It  causes  hypertrophy  of  the  left  auricle,  followed  by  dilata- 
tion. The  blood  is  then  dammed  back  into  the  pulmonary 
veins,  and  the  right  ventricle  hypertrophies  and  then  becomes 
dilated.     The  left  ventricle  is  about  normal  in  size. 

Inspection. — The  apex  beat  is  about  in  the  normal  position. 

Palpation. — A  rough  presystolic  thrill  at  or  near  the  apex, 
ending  abruptly  with  the  apex  beat  against  the  chest. 

Pei^cussion. — Dulness  increased  to  the  right  of  the  sternum. 

Auscultation. — Rough  presystolic  murmur  heard  best  at  or 
near  the  apex  beat.  This  ends  abruptly  when  the  apex  beat 
occurs.     The  second  pulmonic  sound  is  accentuated. 

Pulse. — Small. 

Aortic  Stenosis  or  Obstruction. — This  is  an  obstruction  at 
the  aortic  orifice,  due  to  thickening  or  adhesions  of  the  valve 
segments. 

It  is  rarely  seen  alone  in  children.  The  accompanying  mur- 
mur is  frequently  mistaken  for  a  functional  or  hemic  murmur. 
It  causes  hypertrophy  of  the  left  ventricle,  followed  by  dila- 
tation, and  then  mitral  insufficiency  and  its  consequences. 

Inspectioi7. — Apex  beat  displaced  downward  and  to  the  left. 

Palpation. — Impulse  usually  strong.  Sometimes  a  systolic 
thrill  at  the  apex. 


HEART  AM)  CIRCULATION.  227 

Percussion. — Enlarged  area  ofdulness,  especially  to  the  left. 

Auscultation. — Loud  systolic  murmur,  heard  best  in  the 
second  intercostal  space  to  the  right  of  the  sternum  and  trans- 
mitted to  the  vessels  in  the  neck.   Aortic  sound  feeble  or  absent. 

Pulse. — (Pulsus  tardus.)  Pulse  slow,  not  frequent,  and 
wave  slow  to  rise. 

Aortic  Insufficiency  or  Regurgitation. — Leakage  at  the 
aortic  orifice.  This  is  very  rare  in  childhood.  It  causes 
dilatation  and  hypertrophy  of  the  left  ventricle.  The  ventri- 
cle may  become  very  large.  Later  there  is  further  dilatation 
of  the  left  ventricle  until  mitral  insufficiency  and  all  its 
sequences  are  produced. 

Inspection  and  Palpation. — Apex  beat  forcible;  displaced 
downward  to  the  left.  There  may  be  bulging  of  the  precor- 
dium. 

Percussion. — Area  of  dulness  enlarged,  especially  to  the 
left  and  downward. 

AusGuUaMon. — There  is  a  diastolic  murmur  heard  best  over 
the  second  intercostal  space  to  the  right  and  transmitted 
downward  along  the  sternum.  There  is  sometimes  a  presys- 
tolic murmur  heard  at  the  apex  (Flint  Murmur). 

Pulse. — Water-hammer  or  "  Corrigan  "  pulse,  which  is 
quite  characteristic.  There  is  a  full,  sudden  rise  and  a  very 
sharp  fall  to  the  pulse  wave.  A  capillary  pulse  may  be  seen  under 
the.  finger-nails  or  by  pressing  a  piece  of  glass  over  the  lips. 

Tricuspid  Insufficiency  or  Regurgitation. — This  is  a  leakage  at 
the  tricuspid  orifice,  due  to  lesions  of  the  valve  or  to  dilatation 
of  the  right  ventricle.  It  may  be  secondary  to  mitral  disease  or  to 
diseases  of  the  lungs,  causing  obstruction  of  the  pulmonary  veins, 
as  chronic  pleurisy,  emphysema,  chronic  interstitial  pneumonia. 

Diagnosis. — This  is  chiefly  from  functional  and  hemic 
murmurs  (see  same).  Too  much  stress  is  usually  laid  on  mur- 
murs and  not  enough  on  the  changes  taking  place  in  the  heart. 

Physical  Signs. — There  is  enlargement  of  the  area  of  dul- 
ness, especially  to  the  right  of'  the  sternum,  a  systolic  murmur 
heard  best  over  the  lower  end  of  the  sternum,  and  a  systolic 
pulse  in  the  veins  of  the  neck. 

The  other  forms  of  heart  lesions,  tricuspid   stenosis,  pul- 


228  DISEASES  OF  INFANTS  AND   CHILDREN. 

monaiy   stenosis,   and    insufficiency,  are   always   congenital. 
(See  Congenital  Malformation  of  the  Heart.) 

Prognosis. — Very  trifling  lesions  may  sometimes  be  re- 
covered from.  In  the  main  the  ultimate  outlook  is  grave. 
Children  contracting  heart  lesions  early  in  life  may  not  die 
at  the  time,  but  are  liable  to  fail  about  puberty  or  imme- 
diately afterward.  Recurrent  attacks  of  endocarditis  increase 
the  danger  of  rupture  of  compensation,  as  does  every  other 
illness. 

Treatment. — With  perfect  compensation  a  quiet  out-of- 
door  life,  with  moderate  exercise,  is  to  be  recommended ; 
exercise  to  be  regulated  by  the  child's  condition  and  the 
effect  produced.  When  rupture  of  compensation  is  threat- 
ened, rest  in  bed  and  heart  tonics  should  be  used.  Rest  in 
these  cases  is  of  the  utmost  importance.  Digitalis  and 
strychnin  are  the  most  useful  heart  stimulants.  Infusion  of 
digitalis  is  of  great  service  when  there  is  dropsy  or  enlarge- 
ment ;  salines  or  calomel  may  be  given  at  the  same  time. 
Tonics,  especially  iron  and  arsenic,  are  useful.  Morphia  is 
the  best  drug  to  relieve  the  sleeplessness,  nervousness,  and 
dyspnea  due  to  broken  compensation.  Applications  of  cold 
or  counterirritation  are  useful  to  relieve  pain.  Heart  failure 
is  best  met  by  Hoffmann's  anodyn,  ether,  whisky,  and  aro- 
matic spirits  of  ammonia  internally  and  strychnia  hypoder- 
matically. 

MYOCARDITIS.1 

Definition. — Inflammation  and  degeneration  of  the  heart 

muscle. 

Etiology.— In  children  it  is  most  frequently  seen  in  the 
infectious  diseases,  especially  diphtheria  and  scarlet  fever. 
Adherent  pericarditis  may  be  a  cause. 

Pathology. — There  is  cloudy  swelling  or  fatty  or  hyalin 
degeneration  of  the  heart  muscle,  and  infiltration  between 
the  heart  muscle  fibers  with  small  round  cells.  It  may  be 
acute  or  chronic. 

Symptoms. — There  may  be  no  symptoms.     If  the  dis- 

1  Koplik,  Med,  News,  March  31, 1900,  p.  481.  Knox  and  Sohorer,  "  Bhab- 
domyoma  of  the  Heart  Muscle,"  Archives  of  Pediatrics,  August,  1906,  p.  561. 


HEART  AND   CTRCULATIOX.  229 

ease  is  marked  there  is  a  feeble  heart,  with  pallor,  fainting 
attacks,  and  dyspnea.  The  apex  beat  is  feeble  or  not  to  be 
made  out.  There  is  frequently  dilatation  of  the  heart  with 
symptoms  of  insufficiency.  This  is  seen  in  diphtheria  and 
scarlet  fever.  The  sudden  death  occurring  in  these  diseases 
is  usually  from  myocarditis. 

Diagnosis. — On  the  above  symptoms.  It  is  difficult  or 
impossible  in  many  cases. 

Prognosis. — Always  guarded.  Sudden  death  may  occur, 
especially  on  sudden  exertion. 

Treatment. — Rest  in  bed,  avoidance  of  sudden  exertion, 
tonic,  and  general  supporting  treatment.  Strychnia  is  the 
most  valuable  drug.  Morphin  hypodermatically  may  be  of 
service  in  repeated  fainting  attacks. 

HEMIC  AND  FUNCTIONAL  MURMURS. 

These  are  frequently  heard  in  anemia  and  in  acute  febrile 
diseases,  and  are  often  mistaken  for  organic  heart  disease. 

The  hemic  murmur  is  heard  over  the  base  of  the  heart,  is 
inconstant  and  variable,  and  sometimes  may  be  altered  by 
changing  the  position  of  the  patient.  Such  a  murmur  often 
may  be  heard  over  the  entire  chest  and  in  the  vessels  of  the 
neck,  but  is  not  transmitted  in  any  particular  direction.  A 
venous  hum  may  often  be  heard  over  the  vessels  in  the  neck. 
There  are  no  other  signs  of  organic  disease. 

Treatment. — Treat  the  anemia. 

FUNCTIONAL  HEART  DISORDERS* 

These  are  rare  in  early  childhood,  but  are  seen  frequently 
as  puberty  approaches. 

Etiology. — Functional  disturbances  are  most  frequently 
seen  in  children  of  neurotic  parents.  Tea,  coffee,  tobacco, 
fright,  and  masturbation  are  set  down  as  causes.  They  may 
follow  infectious  diseases. 

Symptoms. — Attacks  of  palpitation  are  the  most  fre- 
quent.     Tachycardia   (rapid    heart)   and   bradycardia    (slow 


230  DISEASES  OE  INFANTS  AND   CHILDREN 

heart)  may  also  be  seen.  Other  symptoms  may  be  present, 
as  flushing  or  pallor,  perspiration,  dizziness,  headaehe,  buzzing 
in  the  ears,  and  cyanosis. 

Diagnosis. — There  is  usually  more  complaint  from  func- 
tional than  from  compensated  organic  disease.  The  absence 
of  the  physical  signs  of  organic  disease  is  the  main  point. 

Prognosis.— Usually  good. 

Treatment. — The  underlying  disease  should  be  treated. 
Iron  and  arsenic  should  be  used  for  anemia.  Fresh  air, 
good  food,  plenty  of  sleep,  and  but  little  study  and  worry 
are  the  best  things.  Avoid  tea,  coffee,  and  tobacco.  Bro- 
mids  may  be  used  for  the  acute  attacks. 

DISEASES  OF  THE  BLOOD-VESSELS. 

Atheroma. — Degeneration  of  the  arteries  is  rarely  seen 
in  early  life,  but  does  occur  even  in  infants.  Contracted 
kidneys  are  seen  as  an  accompaniment. 

Aneurism. — This  is  very  rare  in  young  people,  but  has 
been  met  with.  The  arch  of  the  aorta  is  the  most  frequent 
site.  Syphilis  is  the  usual  causal  factor,  but  is  not  present 
in  all  cases. 

Arterial  Hypoplasia. — This  is  a  congenital  narrowing 
of  the  arteries,  especially  of  the  aorta.  Chlorosis  may  be 
caused  by  it,  and  other  malformations  or  imperfect  develop- 
ments, usually  of  the  genitals,  may  be  present.  (See  Status 
Lymphaticus.) 

Embolism. — This  is  rare  in  early  life.  Pieces  of  vege- 
tations in  endocarditis  may  become  detached  and  swept  along 
in  the  blood  current  until  they  are  stopped  in  a  small  artery. 
The  symptoms  depend  on  the  location  of  the  artery.  They 
are  most  marked  in  organs  having  terminal  arteries,  as  brain, 
lungs,  kidneys,  and  spleen. 

Thrombosis. — This  is  common  in  the  right  side  of  the 
heart  just  before  death.  It  has  no  clinical  significance.  It 
may  occur  during  life  from  infectious  diseases  or  pressure. 
Thrombosis  of  the  sinuses  of  the  brain,  of  the  vena  cava, 
internal  jugular,  and  even  of  the  aorta  have  been  reported. 


THE  BLOOD  IN  INFANCY  AND  CHILDHOOD.      231 


THE  BLOOD  IN   INFANCY  AND   CHILDHOOD. 

Number  of  Red  Blood-cells. — At  birth  the  average 
is  from  4,500,000  to  0,500,000  per  cubic  millimeter.  This 
Dumber  diminishes  during  the  first  weeks,  and  during  the 
first  year  the  average  is  5,500,000 ;  5,000,000  may  be  takeu 
as  an  average  for  later  childhood. 

Abnormalities  of  the  Red  Cells. — Polychromasia. — 
This  term  is  applied  to  a  brownish  stain  taken  with  Ehrlich's 
triaeid  dye  by  some  of  the  cells  iu  the  severe  anemias.  This 
may  be  seen  normally  in  the  fetal  blood  and  in  marrow  cells. 

Nucleated  Red  Cells. — Normoblasts. — Normal  size 
with  dark-staining  nucleus.  Seen  iu  mild  and  severe  anemia, 
disease  of  the  bone  marrow,  and  in  severe  leukocytosis. 

Megaloblasts  or  G-igantoblasts. — These  are  very  large  cells, 
10  to  20  ijl  in  diameter,  with  various-shaped  nuclei  and  poly- 
chromasia. Seen  in  very  young  infants  and  in  pernicious 
anemia. 

Microcytes. — Small  red  cells  4  to  10  p.  in  diameter,  seen  in 
chlorosis  and  in  severe  anemias. 

Megalocytes. — Large  red  cells  10  to  20  a  in  diameter, 
seen  in  severe  anemias.  They  are  taken  as  indicating  blood 
regeneration. 

Poikilocytes. — Irregularly  shaped  cells  seen  in  severe 
anemias. 

Hemoglobin. — This  is  high  at  birth,  usually  above  100 
on  von  FleisehPs  scale.  It  falls  to  100  by  the  second  week, 
and  gets  lower,  until  the  third  month,  reaching  from  60  to 
80.  After  the  second  year  it  increases  to  about  puberty. 
It  is  very  variable  in  childhood. 

White  Blood-cells.  —  Ehrlich^s  classification  is  as 
follows  : 

Lymphocytes. — (Small  mononuclear  leukocytes.)  Size  of 
a  red  blood-cell,  with  a  large  deeply-staining  nucleus.  The 
small  rim  of  protoplasm  about  the  nucleus  stains  more  deeply 
with  basic  dyes. 

Large  Mononuclear  Leukocytes  and   Transitional  Forms. — 


232 


DISEASES  OF  INFANTS  AND   CHILDREN. 


Hb.  Red  cells. 

110  i  6.000,000 

100  "  5,500,000 

90  "  5,000,000 

80  "  4,500,000 

70  "  4,000,000 

60  "  3,500,000 

50  "■  3,000,000 


New-  2d 

born.       week. 


6th 

month. 


3d 
year. 


./*: 


<? 


-r— V^ 


Fig.  61.— Proportion  of  hemoglobin  and  red  corpuscles  throughout  infancy 

(Hutchison). 


New-      ] 
born,  w 

1st 
2ek. 

6th 

month. 

1st                    3d                         6th 

year.              year.                    year. 

15,000 

\ 

10,000 

V 

-Tot*  j     , 

i 

7,500 

■*    \ 

V 

\ 

**  »  »  . 

••..  % 

♦  ^ 

^*<^ 

5,000 

A 

% 

4,000 

3,000 

*  *.. 

2,000 

1 

•»_ 

Fig.    62.— Absolute  number  of  leukocytes  per  cubic  millimeter  at  different 
a,  Polynuclear:  b,  lymphocytes  (Hutchison). 

Two  or  three  times  larger  than  the  preceding,  with  the  oval 
nucleus  not  quite  in  the  center.  Nucleus  does  not  stain  as 
deeply  as  preceding,  but  darker  than  the  surrounding  proto- 


THE  BLOOD  IN  INFANCY  AND   CHILDHOOD.       233 

plasm.     The  nucleus   of  the   transitional   cells  is  irregular, 
stains  darker,  and  may  contain  a  few  neutrophilic  granules. 

Polymorphonuclear  Neutrophilic  Leukocytes,  Usually  Called 
Polynuclears. — Slightly  smaller  than  preceding.  Xucleus  is 
composed  of  several  parts  joined  together  ;  stains  deeply  with 
basic  dyes.  The  protoplasm  of  the  cell  is  filled  with  small 
granules,  staining  with  neutral  dyes. 


1st 
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3d 

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6th 
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12th 
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Carstanjen). 


Eosinophils. — Same  as  preceding,  but  the  granules  are 
larger  and  stain  deeply  with  acid  dyes. 

Mast  Cells. — Much  like  preceding,  except  the  nucleus  may 
be  mono-  or  polynuclear  and  the  granules  stain  with  basic 
dyes. 

Abnormal  White    Cells. — Myelocytes. — Found    nor- 


234 


DISEASES  OF  INFANTS  AND   CHILDREN. 


mally  in  bone  marrow.  A  very  large  round  or  nearly  round 
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Eosinophilic  Myelocytes. — Like  preceding,  except  the  gran- 
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r^j 

> 

s.> 

*!  .' 

nr- 

4 

/r 

<?.r 

'/V£> 

ft? 

it- 1 

:S. 

Fig.  64.— Differential  percentage  counts  throughout  life  (Hutchison,  after  Carstanjen) 

Nongranular  Myelocytes  may  be  seen  in  severe  anemias. 

Degenerated  Leukocytes. — Stain  irregularly  and  may  con- 
tain vacuoles  and  no  nuclei. 

Blood-plates. — Small  cells  half  size  of  a  red  blood-cell, 
colorless,  and  usually  clumped  together.  Their  significance 
is  not  known. 


THE  BLOOD  IN  INFANCY  AND  CHILDHOOD.      235 

Blood-dust. — Numerous  highly  refractile,  actively  mov- 
ing bodies  seen  in  fresh  blood.  These  are  supposed  to  be 
granules  from  the  eosiuophiles. 

FREQUENCY  OF  THE  VARIOUS  FORMS  OF  LEUKOCYTES. 

Infancy.  Adult  (Cabot). 

Lymphocytes 40-60  20-30  per  cent. 


Large  mononuclears 4-12  4- 

Polynuclears 20-40  62-72        u 

Eosinophils 2-4  £-4        " 


Mast  cells 


The  total  number  per  cubic  millimeter  is  somewhat  larger 
in  infancy  than  in  adults.  At  birth  they  are  from  12,000  to 
25,000.  This  number  diminishes  rapidly  during  the  first 
few  days  to  9,000  to  14,000.  In  childhood  6,000  to  12,000 
may  be  regarded  as  an  average. 

SIGNIFICANCE   OF  BLOOD  CHANGES* 

Red  Blood-cells. — The  number  is  diminished  in  pri- 
mary and  secondary  anemia. 

Normal  in  chlorosis. 

Increased  in  cyanosis,  in  high  altitudes,  and  at  sea  coast. 

Hemoglobin. — The  total  quantity  is  diminished  in  all 
forms  of  anemia.  The  corpuscle  contains  less  in  chlorosis 
and  secondary  anemia.  The  corpuscle  contains  a  normal 
amount  or  more  in  pernicious  anemia. 

White  Blood-cells. — Lymphocytes. — Normally  more 
present  than  in  adults,  and  in  many  severe  diseases  of  child- 
hood the  blood  tends  to  revert  to  the  infantile  type. 

Lymphocytosis  (increased  number  of  lymphocytes)  is  seen 
in  lymphatic  leukemia,  whooping-cough,  scurvy,  rickets,  and 
hereditary  syphilis. 

Leukocytosis  (neutrophilic). 

Physiologic. — This  is  marked  in  infancy.  Is  seen  in  the 
newborn,  after  meals,  after  massage,  cold  baths,  exercise,  etc. 

Pathologic. — In  numerous  conditions ;  in  toxemias,  after 
severe  hemorrhages  ;  in  inflammatory  conditions,  when  there 
is  pus-formation,  septicemia  and  pyemia,  pneumonia,  etc. 


236  DISEASES  OF  INFANTS  AND  CHILDREN. 

Normal  Number  of  Leukocytes  and  Disease. — There  are 
many  diseases  where  leukocyte  count  is  unaffected,  as  malaria, 
typhoid,  tuberculosis,  mumps,  measles. 

Leukopenia. — (Diminution  of  the  white  blood-cells.) — Seen 
in  severe  anemias,  malnutrition,  leukemia  complicated  by  in- 
fectious diseases,  and  in  severe  disease  when  there  is  no  re- 
action— i.  e.j  leukopenia  in  pneumonia  usually  means  a  fatal 
prognosis. 

Eosinophilia. — Found  in  many  conditions,  among  which 
may  be  mentioned  :  the  infection  of  the  body  with  animal  para- 
sites, as  in  trichinosis,  in  malignant  tumors,  in  many  skin 
diseases,  in  leukemia,  scarlet  fever,  etc. 

Mast  Cells. — Said  to  be  more  numerous  in  the  lower  classes. 
Are  increased  in  some  forms  of  leukemia  and  some  other 
diseases. 

Myelocytes. — Seen  in  most  cases  of  leukemia,  in  small  num- 
bers in  severe  anemias,  in  the  leukocytosis  of  some  diseases, 
as  diphtheria,  and  after  any  severe  blood  disturbances,  as 
asphyxia,  uremia,  etc. 

BLOOD  CHANGES  IN  DISEASE. 

Pneumonia. — Diminution  of  hemoglobin  and  of  red 
blood-cells,  leukocytosis,  except  in  very  mild  and  very  severe 
forms.  Absence  of  leukocytosis  in  severe  cases  means  a 
grave  prognosis.  Eosinophiles  diminish,  and  their  reappear- 
ance means  the  height  of  the  disease  is  over.  Leukocytosis 
may  be  of  value  in  diagnosis  of  doubtful  cases.  Leukocyto- 
sis after  normal  has  been  once  reached  usually  means  a  com- 
plicating empyema. 

Diphtheria. — Great  diminution  in  hemoglobin  and  red 
blood-cells  after  a  few  days.  Leukocytosis  usually  present. 
Myelocytes  in  severe  cases ;  where  they  exceed  2  per  cent.,  a 
fatal  prognosis  may  be  made  (Engel). 

Scarlet  Fever. — Diminished  hemoglobin  and  red  cells. 
Leukocytosis  varies  with  intensity  of  the  disease.  Eosino- 
philes, beginning  after  two  or  three  days,  increasing  to  8  to 
15  per  cent,  in  two  or  three  weeks,  gradually  reaching  normal 


THE  BLOOD  IN  INFANCY  AND  CHILDHOOD,      237 

about  the  sixth  week.  Eosinophiles  are  increased  in  favora- 
ble cases  and  decreased  in  unfavorable  ones  (Neusser).  Leu- 
kocytosis, after  third  day,  is  of  value  in  differentiating  scarlet 
fever  from  measles  in  doubtful  cases. 

Whooping-cough. — Marked  leukocytosis  comes  on 
early  and  persists  through  the  entire  disease.  It  averages 
25,000  to  30,000,  and  is  more  marked  under  four  years  of 
age.  Half  the  cells  are  lymphocytes.  Leukocytosis  is  useful 
in  differentiating  spasmodic  cough  from  other  causes. 

Meningitis. — Septic  meningitis  has  leukocytosis.  Cere- 
brospinal fever  has  leukocytosis  in  about  two-thirds  of  the 
cases.  Tuberculous  meningitis  may  or  may  not  be  accom- 
panied by  leukocytosis. 

Congenital  Cyanosis. — Increase  in  hemoglobin  and  in 
number  of  red  cells  (6,000,000  to  12,000,000).  There  may 
be  an  increase  in  the  leukocytes. 

CHLOROSIS. 

(Green  Sickness.) 

Definition. — A  primary  anemia  with  a  lowering  of  the 
hemoglobin  without  any  great  decrease  of  the  red  blood-cells, 
except  in  severe  cases. 

Etiology. — L^sually  occurs  about  or  just  after  puberty, 
It  may  occur  earlier  and  is  rarely  seen  in  boys.  Previous 
ill  health,  overcrowding,  lack  of  fresh  air  and  sunshine,  and 
overwork  are  the  predisposing  causes. 

Pathology. — Some  fatal  cases  have  shown  a  small  heart 
and  congenital  narrowness  of  the  aorta  and  other  vessels. 
Complicating  tuberculosis  or  ulcer  of  the  stomach  is  the  most 
frequent  cause  of  death. 

Symptoms. — Blood-changes  are  characteristic.  Low 
hemoglobin,  20,  30,  or  40  on  von  Fleischl's  scale  is  com- 
mon ;  red  blood-cells,  normal  in  number  or  nearly  so  ;  in 
severe  cases  poikilocytosis ;  no  leukocytosis.  Other  symp- 
toms are  the  general  symptoms  of  anemia ;  a  greenish  pallor ; 
weakness  without  loss  of  flesh  ;  nervousness  ;  perversions  of 
appetite  (pica)  ;   and  in  girls,  menstrual  disorders.     Hemic 


238  DISEASES  OF  INFANTS  AND  CHILDREN. 

murmurs  are  heard  over  the  base  of  the  heart  and  larger  ves- 
sels. The  heart  may  be  dilated  or  the  left  ventricle  hyper- 
trophied. 

Complications. — Constipation,  gastric  ulcer,  gastralgia, 
hyperacidity,  amenorrhea,  albuminuria. 

Prognosis. — Good,  but  relapses  are  common.  It  may 
last  months  or  even  years. 

Treatment. — Fresh  air,  sunshine,  good  food,  rest,  and 
baths  if  there  is  a  reaction  after  them.  Solutions  of  iron  and 
manganese  peptonate  or  Blaud's  pills  may  be  given.  Saline 
laxatives  are  needed.  In  hyperacidity  give  alkalis,  especially 
calcined  magnesia.  Arsenic  may  be  tried,  but  is  of  less  value 
than  iron. 

PERNICIOUS  ANEMIA. 

Definition. — A  grave  anemia,  which  is  usually  fatal, 
having  the  characteristic  blood-changes  given  below. 

Etiology. — Very  rare  in  infancy.  It  may  follow  a 
severe  secondary  anemia,  it  may  be  caused  by  intestinal  para- 
sites, or  it  may  come  on  without  assignable  cause. 

Pathology. — Severe  anemia  of  all  the  organs  and  fatty 
degeneration  in  most  of  them.  Small  hemorrhages  ;  deposits 
of  iron  in  the  liver ;  hemolymph  glands  may  be  enlarged  and 
congested ;  bone  marrow  is  dark  red  and  soft  with  numerous 
nucleated  reds  ;  there  may  be  atrophy  of  the  stomach  mucosa. 

Blood-changes. — Specific  gravity  lowered  ;  hemoglobin 
very  low,  but  color  index  of  the  cell  normal  or  above 
normal ;  great  reduction  in  the  number  of  the  red  cells  ; 
megalocytes  common  ;  marked  poikilocytosis ;  red  cells  may 
be  polychromatophilic  ;  normoblasts  and  megaloblasts  present; 
polymorphonuclear  leukocytes  diminished. 

Symptoms. — The  symptoms  are  those  of  a  severe  anemia. 
Skin  has  a  light  lemon  tint ;  there  may  be  slight  edema ; 
there  may  be  effusion  into  the  serous  cavities ;  there  may  be 
but  little  emaciation.  Great  weakness ;  later  prostration. 
Nervousness  and  sleeplessness.  Heart  may  be  dilated ; 
hemic  murmurs  common.  Shortness  of  breath  on  exertion. 
Digestive  disturbances. 

Diagnosis.— Great  diminution  of  red  cells,  high  color 


THE  BLOOD    IS  INFANCY  AND   CHILDHOOD.      239 

index,  diminution  of  polymorphonuclears.  An  eosinophilia 
points  to  intestinal  parasites.  Retinal  hemorrhage  is  nearly 
always  present  in  pernicious  anemia  and  rarely  seen  in  sec- 
ondary anemias  (Hesse).1 

Prognosis. — Bad  ;  recovery  is  of  very  rare  occurrence. 
High  color  index,  increase  in  size  of  red  cells,  degenerative 
changes,  numerous  megaloblasts,  few  or  no  normoblasts,  and 
lymphocytosis  are  all  bad  signs. 

Treatment. — Good  hygiene  and  diet.     Mountain  or  sea 

air.     Baths,  glycerin  extract  of  red  bone  marrow,  arsenic, 

and  for  digestive  symptoms  bitter  tonics  and  hydrochloric 

acid. 

SECONDARY  ANEMIA. 

Definition. — A  secondary  anemia  is  one  that  is  due  to 
some  known  underlying  cause.  The  blood-changes  are  char- 
acteristic. 

Etiology. — Very  common  in  infancy  and  young  chil- 
dren. It  may  be  due  to  lack  of  food,  bad  hygiene,  drugs,  para- 
sites (malaria),  hemorrhage,  or  practically  any  disease. 

Blood- changes. — Remember  that  in  infancy  any  change 
tends  to  bring  blood  back  to  the  embryonic  type.  The  num- 
ber of  the  red  cells  and  the  hemoglobin  are  lowered  propor- 
tionately. The  specific  gravity  is  lowered.  There  is  poikilo- 
cytosis  in  the  severer  cases.  Mierocytes  may  be  present,  as 
may  also  nwalocvtes.  Normoblasts  are  seen  in  the  average 
cases  and  megaloblasts  may  be  present  in  the  severe  ones. 
There  may  or  may  not  be  leukocytosis. 

Symptoms. — The  symptoms  common  to  all  anemias  are 
present :  pallor,  languor,  digestive  disturbances.  In  infants 
and  children  irritability  and  peevishness  are  nearly  always 
present.     There  may  be  slight  edema  and  hemorrhages. 

Prognosis. — This  depends  on  the  cause.  Where  it  can 
be  removed  the  prognosis  is  usually  good.  Red  blood-cells 
below  2,000,000,  megalocytes,  megaloblasts,  polychromasia, 
and  a  high  color  index  are  all  bad  signs. 

Treatment. — Remove  cause  when  possible,  good  hygiene, 
fresh  air,  and  good  food.     Iron,  arsenic,  tonics. 

1W.  d'Este  Eneiy,  "Anemia,  Pernicious,  Diagnosis  of,"  Practitioner, 
December,  1905,  p.  755. 


240  DISEASES  OF  INFANTS  AND  CHILDREN. 

LEUKEMIA. 

( Leukocythemia. ) 

Definition. — Leukemia  is  a  disease  characterized  by  a 
persistent  increase  in  the  number  of  white  blood-cells,  with 
lesions  in  the  spleen,  bone  marrow,  and  sometimes  in  the 
lymph  glands.     Ehrlich  calls  it  a  "  mixed  leukocytosis." 

Etiology. — The  causes  are  unknown.  It  is  rare  in 
infancy  and  childhood,  but  may  be  seen.  The  acute  lym- 
phatic form  is  the  most  frequent  in  early  life.  It  is  more 
common  in  boys.  Congenital  syphilis,  rickets,  malaria,  and 
the  various  infectious  diseases  may  precede  it.  It  has  been 
regarded  by  some  as  having  an  infectious  origin.  Lowit 
claims  to  have  found  a  hemameba. 

Varieties. — (1)  Myelogenous  and  (2)  lymphatic.  The 
lymphatic  has  two  forms  :  acute  and  chronic. 

Pathology. — The  blood  may  contain  so  many  white 
cells  as  to  resemble  pus.  The  bone  marrow  is  affected  in  the 
myelogenous  type,  the  fat  being  largely  replaced  with  red  or 
white  marrow  cells.  The  myelocytes  are  largely  increased. 
The  liver  is  enlarged  and  contains  lymphomatosis  nodules. 
The  spleen  is  enormously  enlarged  and  contains  a  great  in- 
crease in  the  number  of  leukocytes.  In  the  lymphatic  form 
the  lymph  glands  are  enlarged,  but  generally  movable.  The 
lymphoid  structures  in  the  intestinal  tract  and  about  the 
mouth  may  also  be  affected.  In  the  acute  form  the  spleen 
is  moderately  enlarged,  and  there  is  a  great  tendency  to 
petechia  and  hemorrhages.  This  has  been  regarded  by  some 
as  an  infection.  In  the  chronic  form  the  spleen  is  very  much 
enlarged.     Lymphomata  may  be  found  in  the  other  organs. 

Blood-changes. — The  hemoglobin  is  lowered.  The 
red  cells  are  diminished  in  number.  Normoblasts  may  be 
found.  Splenomyelogenous  form.  White  cells  enormously 
increased  in  number.  Myelocytes  numerous.  Polynuclear 
neutrophiles  actually  increased,  but  the  percentage  may  be 
diminished.  Lymphocytes  vary,  being  increased  in  some 
cases  more  than  in  others.  There  is  an  increase  in  eosino- 
philes,  large  mononuclears,  large  eosinophilic  mononuclears, 


THE  BLOOD  IN  INFANCY  AND   CHILDHOOD.      241 

and  mast  cells.  The  last  are  of  considerable  diagnostic  im- 
portance  in  some  cases.  In  the  lymphatic  form  the  small 
mononuclears  arc  enormously  increased,  and  may  be  80  or  90 

per  cent,  of  all  white  cells  present.  There  may  or  may 
not  be  myelocytes.     The  white  cells  may  fall  to  normal  just 

before  death  or  during  some  intercurrent  infectious  disease  as 
typhoid. 

Symptoms. — The  symptoms  are  those  of  an  anemia. 
Onset  is  usually  insidious.  Hemorrhages  are  common.  The 
] tailor,  muddy  skin,  enlarged  glands,  enlarged  spleen  and 
liver  make  a  striking  picture  in  a  developed  case.  There 
may  be  disturbances  of  vision  and  hearing  and  of  the  nervous 
system.     There  may  be  fever. 

Diagnosis. — From  leukocytosis  by  the  actual  increase 
in  the  number  and  percentage  of  polyuuclear  neutropenics. 
The  number  of  white  cells;  is  never  so  high  as  that  which 
may  be  seen  in  leukemia. 

Prognosis. — Unfavorable.  In  early  life  the  course  is 
rapid,  and  cases  last  but  a  few  weeks  or  months.  Occasion- 
ally a  case  may  last  a  year  or  two. 

Treatment. — Rest,  good  hygiene,  and  proper  diet.  Ar- 
senic. The  Rontgen  rays  are  said  to  be  beneficial  when 
applied  over  the  spleen  or  lymphatic  glands. 

SPLENIC  ANEMIA  OF  INFANTS.1 

(Pseudoleukemia  of   Infants  (von  Jaksch,  1889);  Anaemia  Infantum 

Pseudoleucaemica. ) 

Definition. — A  rare  grave  anemia  characterized  by  leu- 
kocytosis, enlargement  of  the  spleen  and  lymph  glands  and 
often  of  the  liver. 

Etiology. — Seen  in  infants,  especially  between  .-even 
and  ten  months,  always  under  four  years.  Rickets  is  present 
in  many  cases. 

Pathology. — Simple  hyperplasia  of  the  spleen  ■;  enlarge- 
ment  of  the  liver  with   infiltration   of  white  cells  ;  enlarge- 

1  Wentworth,  Boston  Med.  and  Surg.  Jour.,  Oct.  3, 1901,  p.  374.  Scott  and 
Telling,  "-  Splenic  Anemia,  Infantile,  Case  of,"  Lancet,  June  17, 1905,  p.  163b. 

16 


242  DISEASES  OF  INFANTS  AND  CHILDREN. 

ment  of  the  lymph-glands.  Bone-marrow  changes  may  he 
present.    Some  observers  believe  that  these  are  due  to  rachitis. 

Blood-changes. — Lowered  specific  gravity;  lowered 
hemoglobin;  great  diminution  of  red  blood-cells;  microcytes, 
megalocytes,  megalo blasts,  and  normoblasts  are  present,  and 
there  is  poikilocytosis ;  leukocytes  increase  and  myelocytes 
may  be  present.  The  large  mononuclears  are  usually  in- 
creased.    The  cells  stain  irregularly  with  the  ordinary  dyes. 

Symptoms. — General  symptoms  of  anemia ;  cachectic 
appearance,  loss  of  appetite,  and  digestive  disturbances. 
Drags  along  with  improvement  and  relapses. 

Diagnosis.— Difficult.  A  term  used  to  classify  little 
understood  cases  of  infantile  anemia.  Any  severe  anemia 
of  infancy  may  be  accompanied  by  leukocytosis.  From 
leukemia  by  recovery  and  lessened  number  of  myelocytes. 

Prognosis. — About  25  per  cent,  of  the  cases  die. 

Treatment. — Good  hygiene  and  proper  diet.  If  there 
is  rickets,  give  cod-liver  oil ;  if  syphilis,  give  mercury,  with 
or  without  iodid  of  potassium,  alternating  with  iron.  Arsenic 
or  iron  may  be  tried. 

HEMOPHILIA.1 

(Hemorrhagic  Diathesis ;  Bleeder's  Disease.) 
Definition. — A  family  and  hereditary  disease,  character- 
ized by  a  tendency  to  severe  hemorrhage  from  slight  causes 
or  spontaneously. 

Etiology. — Heredity  is  the  chief  cause.  It  is  more  com- 
mon in  boys  than  in  girls.  The  tendency  is  transmitted 
through  the  daughters  of  bleeders  even  though  they  may  not 
have  the  disease  themselves.  The  daughter  of  a  bleeder 
family,  herself  a  bleeder,  is  no  more  likely  to  transmit  the 
tendency  than  is  her  non-bleeder  sister.  A  son  of  a  bleeder 
family,  himself  a  bleeder,  should  he  live  to  beget  children, 
does  not  often  transmit  the  disease  to  his  children,  but  to  his 

1  Dunn,  American  Journal  of  the  Medical  Sciences,  1883,  vol.  lxxxv.,  p.  68. 
J.  J.  Wilson,  "  Hemophilia,"  Practitioner,  December,  1905,  p.  829.  R.  C. 
Larrabee,  "  Hemophilia  jn  the  Newborn,"  American  Journal  of  the  Medical 
Sciences,  March,  1906,  p.  497. 


THE  BLOOD  IN  INFANCY  AND   CHILDHOOD.      243 

grandsons  through  his  daughters.  Again,  should  he  have 
non-bleeder  brothers,  their  grandsons  seldom  bleed. 

Pathology. — Unknown.  In  some  cases  the  artery  walls 
have  been  thin  and  degenerated. 

Symptoms. — It  usually  begins  in  the  first  two  years  of 
life,  rarely  after  ten  and  practically  never  after  twenty.  Per- 
sistent hemorrhage,  which  cannot  be  checked  by  ordinary 
means,  follows  slight  injuries  or  occurs  spontaneously  from 
the  mucous  membranes.  Some  cutaneous  hemorrhages  also 
occur.  There  may  be  effusions  of  blood  into  the  joints,  and 
also  other  joint  troubles  not  unlike  rheumatism. 

Prognosis. — Bad.  Almost  all  cases  die  before  they  are 
ten  years  of  age,  and  the  remainder  before  they  are  twenty. 
If  they  live  beyond  that  age  they  are  liable  to  die  of  some 
other  disease. 

Treatment. — Protect  such  children  from  injury.  Fur 
the  hemorrhage,  rest  and  local  pressure  and  styptics.  Gelatin, 
calcium  chlorid,  thyroid  extract,  sulphate  of  soda,  perchlorid 
of  iron,  and  adrenalin  are  among  the  numerous  drugs  recom- 
mended. Injection  of  normal  blood  serum  has  been  sug- 
gested. 

PURPURA. 

Definition. — Spontaneous  subcutaneous  hemorrhages  are 
called  purpura.  These  may  be  small  (petechia?)  or  large 
(ecchymoses).  When  the  skin  is  alone  affected  it  is  called 
purpura  simplex.  When  there  are  hemorrhages  from  the 
mucous  membranes  it  is  called  purpura  hemorrhagica. 

Etiology. — Purpura  may  be  regarded  as  a  symptom  and 
may  be  due  to  many  causes.  The  most  important  are  the 
infectious  diseases  ;  cachectic  conditions  ;  from  toxic  sub- 
stances, either  drugs,  as  chlorate  of  potassium,  or  from 
ptomaines ;  mechanical,  as  after  the  removal  of  splints;  in 
whooping-cough,  in  hemorrhage  into  the  adrenal,  scurvy, 
and  lastly  neurotic. 

Symptoms. — The  appearance  of  the  hemorrhagic  spots 
and  the  hemorrhages,  together  with  the  clinical  picture  of  the 
disease  which  causes  it. 


244  DISEASES  OF  INFANTS  AND   CHILDREN. 

Diagnosis. — This  is  from  the  purpuric  diseases  given 
below. 

Prognosis. — As  a  rule,  purpura  occurring  in  the  course 
of  a  serious  disease  is  a  bad  sign. 

Treatment. — Treat  the  original  disease.  Prevent  bruis- 
ing. An  antiscorbutic  diet  may  be  tried.  Adrenalin  and 
similar  preparations  may  be  tried.  Ergot,  calcium  ehlorid, 
and  many  other  drugs  are  recommended.  The  injection  of 
normal  blood  serum  has  been  suggested. 

PURPURIC  DISEASES. 

Purpura  Rheumatica  (Schonlein's  Disease). — This 
rarely  occurs  under  five  years  of  age.  In  addition  to  the 
clinical  picture  of  acute  rheumatism  there  is  a  purpura,  often 
urticaria,  and  erythema  multiforme  as  well.  There  may  be 
edema.  The  condition  lasts  a  couple  of  weeks  and  tends  to 
relapse. 

Treatment. — Antirheumatic. 

Purpura  Simplex. — The  hemorrhages  are  limited  to 
the  skin.  It  may  appear  suddenly,  or  there  may  be  indispo- 
sition for  several  days,  with  vomiting,  diarrhea,  and  slight 
fever  when  the  purpura  appears.  It  lasts  from  one  to  four 
weeks.  Relapses  are  common.  Recovery  is  the  rule.  Occa- 
sionally death  occurs. 

Purpura  Hemorrhagica. — (Morbus  maculosus  Werl- 
hofii  is  often  incorrectly  used  for  this.)  This  is  a  severe  dis- 
ease with  prostration,  fever,  nausea,  vomiting,  often  diarrhea, 
and  frequently  albuminuria.  There  is  a  marked  purpuric 
rash  and  hemorrhages  from  the  mucous  membranes ;  these 
may  be  very  severe.  Edema  may  be  present.  Pains  are 
felt  all  over  the  body.  There  may  be  marked  nervous  symp- 
toms, even  delirium  and  coma.  It  lasts  from  one  to  six 
weeks  and  resembles  typhoid,  from  which  it  is  distinguished 
by  the  Widal  reaction.     It  may  terminate  fatally. 

Giant  Purpura  Without  Symptoms.1 — WerlhofPs 
disease  (morbus  maculosus  Werlhofii)  is  a  term  frequently 
applied  incorrectly  to  the  severe  forms  of  purpura. 

1  Werlhofif,  1735 


THE  BLOOD  IN  INFANCY  AND  CHILDHOOD.      245 

Gianl  purpura  is  a  rare  disease  seen  usually  between  five 
and  fifteen  years  of  age.  There  is  a  sudden  onset,  a  hemor- 
rhagic rash,  and  sometimes  hemorrhages  from  the  mucous 
membranes.  There  are  no  symptoms.  The  hemorrhages 
under  the  skin  are  enormous — several  inches  in  diameter. 
Thev  last  about  two  weeks  and  disappear.  There  is  a  ten- 
dency to  frequent  recurrence. 

The  diagnosis  is  easy.  Take  care  to  exclude  scurvy  in 
the  very  young. 

Treatment. — Unsatisfactory.     As  in  purpura. 

Purpura  Fulminans. — This  is  an  acute  fatal  form  of 
purpura  most  frequently  seen  under  five  years  of  age.  Large 
hemorrhages  are  noted  in  the  adrenals.  The  onset  is  sudden, 
with  a  chill  or  convulsion,  vomiting,  high  temperature,  and 
marked  prostration.  The  purpura  comes  on  rapidly  and 
covers  the  entire  body.  Death  takes  place  in  from  ten  hours 
to  three  days. 

Henoch's  Purpura.1 — This  disease  is  seen  most  fre- 
quently in  childhood ;  also  in  later  life. 

Skin  Manifestations. — Usually  purpura,  but  there  may  also 
be  erythema,  exudations,  circumscribed  edema,  or  urticaria. 
Any  or  all  of  these  may  be  present. 

Visceral  Symptoms. — Gastro-intestinal  crises  consisting  of 
pain,  often  with  vomiting  and  diarrhea.  These  last  from  a 
few  hours  to  days.  There  may  be  cerebral  or  pulmouary 
symptoms. 

Arthritic  Changes. — Swelling  of  synovial  sheaths  of  one  or 
more  joints  with  pain. 

The  attacks  recur  at  intervals  of  weeks,  months,  or  years, 
sometimes  manifested  by  one  of  the  above,  sometimes  by 
another,  and  sometimes  in  combination.  The  ultimate  out- 
look is  for  about  25  per  cent,  mortality. 

Treatment. — Between  the  attacks,  good  food,  quiet  out- 
of-door  life,  iron  if  anemic.  During  attacks,  rest  in  bed  and 
protect  from  injury.  Antiscorbutic  diet  may  be  tried  or 
drugs,  as  in  purpura,  although  little  may  be  expected  from 
the  latter. 

1  Osier,  American  Journal  of  the  Medical  Sciences,  January,  1904. 


246  DISEASES  OF  INFANTS  AND  CHILDREN. 

DISEASES  OF  THE  DUCTLESS  GLANDS. 

HODGKIN'S  DISEASE.    (J832.) 

(Pseudoleukemia ;  General  Lymphadenoma  j  Adenia ;  Lymphatic 

Anemia*) 

Definition. — A  disease  in  which  there  is  progressive 
enlargement  of  the  lymph-nodes  and  the  spleen,  with  the 
formation  of  nodules  in  the  internal  organs,  such  as  the  liver, 
kidney,  and  spleen,  etc.,  and  sooner  or  later  a  secondary 
anemia  and  cachexia. 

Etiology. — It  is  a  disease  of  early  life.  In  43  cases 
10  were  under  ten  years  of  age  (Clarke).  The  cause  is 
unknown,  but  it  has  been  suggested  that  it  is  of  infectious 
origin. 

Pathology. — There  is  an  enlargement  of  the  lymph- 
nodes,  the  spleen,  and  lympno- 
matous  nodules  in  the  internal 
organs.  The  marrow  of  the  long 
bones  may  be  involved.  The 
nodes  do  not  tend  to  break  down 
unless  there  is  secondary  infec- 
tion, and  there  is  no  tendency  to 
invade  the  surrounding  tissue,  as 
in  lymphosarcoma.  The  histo- 
logic changes  are  characteristic 
(Reed).1  There  are  proliferation 
of  the  endothelial  and  reticular 
cells  and  an  increase  in  the  lym- 
phoid cells.  There  are  also  giant 
cells  which  differ  from  the  giant  cells  of  tuberculosis.  The 
connective-tissue  stroma  of  the  nodes  is  increased,  and  eosino- 
philes  are  seen  in  the  nodes.  Tuberculosis  is  a  frequent 
secondary  infection. 

Symptoms. — It  resembles  lymphatic  leukemia,  but  there 

is  no  leukocytosis.     It  usually  starts  in  the  neck,  and  the 

nodes   are    first   soft,   but   become    harder,  and    are   rarely 

painful.      They  are  freely  movable,  and  do  not  suppurate 

1  Johns  Hopkins  Hospital  Keports,  1902,  vol.  x. 


Fig.  64  a.— Hodgkin's  disease. 


DISEASES  OF  THE  DUCTLESS  GLANDS.  247 

unless  secondary  infection  takes  place,  and  this  is  rare.  There 
is  often  fever  of  an  irregular  remittent  type.  The  progress 
of  the  disease  is  steady,  but  there  may  be  temporary  remis- 
sions. There  may  be  pressure  symptoms  caused  by  the 
enlarged  nodes  pressing  on  the  trachea,  bronchi,  nerves, 
ureters,  etc. 

Diagnosis. — From  leukemia,  by  the  absence  of  leuko- 
cytosis. From  tuberculosis,  by  the  absence  of  fusion  and 
matting  of  the  nodes,  by  the  tuberculin  test,  and,  best  of  all, 
by  histologic  study  of  an  excised  gland.  Tuberculosis  is  a 
frequent  complication,  and  without  the  histologic  examina- 
tion may  obscure  the  diagnosis.  From  lymphosarcoma,  by 
histologic  study  and  the  absence  of  a  tendency  to  invade 
adjacent  tissue. 

Prognosis. — This  is  unfavorable.  The  usual  duration 
is  from  one  to  four  years  after  the  appearance  of  the  disease, 
but  some  last  only  months.  There  may  be  remissions  from 
time  to  time,  but  sooner  or  later  the  patient  becomes  cachectic, 
and  frequently  dies  from  tuberculosis  or  some  other  intercur- 
rent infection. 

Treatment. — This  is  not  very  satisfactory.  Arsenic  is 
the  best  drug,  and  is  best  administered  hypodermatically,  or 
Fowler's  solution  may  be  given  by  the  mouth.  The  Rontgen 
rays  have  been  used  recently  and  apparently  with  great  ben- 
efit in  selected  cases,  and  further  investigation  should  deter" 
mine  its  exact  value. 

STATUS  LYMPHATICUS.1 

(Lymphatism;  Status  Thymicws.) 

Definition. —  A  condition  characterized  by  a  general 
hypertrophy  of  the  lymphatic  system,  an  enlarged  thymus 
gland,  an  enlarged  spleen,  hyperplasia  of  the  vascular  system, 
particularly  of  the  aorta,  a  chlorotic  condition,  and  a  tendency 
to  sudden  death  from  trifling  causes. 

Etiology. — This  condition  is  frequently  associated  with 
rickets.  It  may  be  seen  at  any  age,  but  is  most  frequent  in 
young  children. 

Symptoms. — The  child  appears  pale  and  flabby.     There 

1  Bloomer,  Bulletin  Johns  Hopkins  Hospital,  1903,  vol.  xiv.,  p.  263. 


248  DISEASES  OF  INFANTS  AND   CHILDREN. 

are  enlarged  tonsils,  adenoids,  and  other  structures  as  given 
above.  Sudden  death  may  call  attention  to  the  condition. 
Death  may  follow  some  slight  accident,  as  a  fall,  or  result 
from  chloroform.  Sometimes  there  is  a  cry  and  a  convul- 
sion and  the  child  drops  dead. 

Diagnosis. — By  the  physical  findings. 

Prognosis. — There  is  a  tendency  for  the  condition  to 
disappear  about  puberty. 

Treatment. — Careful  dieting  to  avoid  convulsions,  due 
to  improper  food.  Good  hygiene.  Cod-liver  oil  in  winter  : 
syrup  of  the  iodid  of  iron  may  be  given.  Iodid  of  potassium 
may  be  tried. 

SIMPLE  ACUTE  ADENITIS. 

Definition. — An  acute  inflammation  of  the  lymph-nodes. 
Either  the  external  or  internal  nodes  may  be  affected.  The 
external  frequently  suppurate,  while  the  internal  rarely  do. 

etiology. — About  three-fourths  of  cases  are  seen  under 
two  years  of  age,  and  the  lesion  is  usually  secondary  to  an 
adjacent  inflammation,  as  pharyngitis,  bronchitis,  or  tonsil- 
litis, or  it  may  be  due  to  eczema  of  the  scalp,  carious  teeth, 
or  stomatitis,  or  it  may  be  caused  by  the  infectious  diseases, 
as  German  measles. 

Pathology. — There  is  swelling  in  the  node,  due  to  con- 
gestion and  to  a  hyperplasia  of  the  lymphoid  cells.  The 
nodes  may  suppurate  or  they  may  subside  entirely  after  a  few 
weeks,  or  they  may  remain  enlarged  and  hard  for  some  time. 

Symptoms. — There  are  always  the  symptoms  of  the 
original  disease,  which  may  be  so  slight  as  to  pass  unnoticed. 
The  cervical  glands  are  the  most  frequently  affected.  The 
swelling  comes  on  gradually.  They  are  painful,  tender,  and 
there  may  be  redness  of  skin.  Suppuration,  when  it  takes 
place,  usually  starts  before  the  first  or  second  week,  but  it 
may  be  delayed  for  three  or  even  four  weeks.  After  the  pus 
is  discharged  the  healing  is  usually  quite  rapid.  When  sup- 
puration does  not  occur  the  nodes  remain  swollen  from  a  week 
to  two  months,  and  gradually  become  smaller  and  harder. 
Recurrences  are  not  infrequent.  Fever  is  usually  present  at 
the  height  of  the  disease.     The  bronchial  lymph-nodes  are 


DISEASES  OF  THE  DUCTLESS  GLANDS.  249 

infected  in  lesions  of  the  lungs  and  bronchi,  and  may  be  the 
cause  of  continued  fever.  The  mesenteric  nodes  may  be  in- 
fected in  intestinal  disorders. 

Diagnosis. — The  age  of  the  child  and  the  acute  onset 
usually  suffice  to  exclude  tuberculosis,  but  after  two  years  of 
age  tuberculosis  of  the  nodes  is  common.  The  location  of 
mumps  in  the  parotid  region,  with  the  lobe  of  the  ear  as  the 
center  of  the  swelling,  and  a  history  of  exposure  are  usually 
sufficient  to  differentiate  this  disease.  The  other  affections 
of  the  lymph-nodes  are  chronic. 

Treatment. — Where  the  local  cause  is  apparent,  it  should 
be  removed  if  possible.  The  nodes,  throat,  or  teeth  should 
receive  prompt  attention.  Internally,  iodid  of  potassium  or 
the  syrup  of  the  iodid  of  iron  may  be  used.  Externally, 
local  applications  of  heat  or  cold — cold  if  there  is  swelling 
and  congestion,  and  heat  if  the  process  is  one  of  pus  forma- 
tion. Five  to  10  per  cent,  ichthyol  ointment  is  one  of  the 
best  external  applications.  If  suppuration  takes  place  the 
abscess  should  be  opened,  it  being  usually  better  to  wait  until 
suppuration  is  marked,  and  make  rather  a  small  opening. 

SIMPLE  CHRONIC  ADENITIS. 

Definition. — A  chronic  inflammation  and  enlargement 
of  the  lymph-nodes. 

etiology. — Repeated  attacks  of  adenitis  or  a  long-stand- 
ing irritation,  as  a  chronic  eczema  or  a  carious  tooth,  is  the 
most  frequent  cause.  It  is  one  of  the  features  of  the  status 
lymphaticus. 

Pathology. — The  nodes  are  enlarged,  hard,  and  show 
hyperplasia  of  the  cells  and  connective  tissue  changes. 

Symptoms. — The  chronic  enlargement  of  the  disease  is 
the  only  symptom.  The  glands  are  hard,  usually  not 
tender,  and  they  suppurate  but  rarely. 

Diagnosis. — Usually  from  tuberculosis  or  Hodgkin's 
disease.  A  node  may  be  removed  for  microscopical  exami- 
nation if  very  strong  doubt  exists. 

Prognosis. — Good  if  cause  can  be  removed. 

Treatment. — Remove  cause,  as  carious  teeth,  adenoids, 
or  enlarged  tonsils.     Cod-liver  oil,  syrup  of  iodid  of  iron, 


250  DISEASES  OF  INFANTS  AND  CHILDREN. 

iodid  of  potassium,  and  Fowler's  solution  of  arsenic  may  all 
be  recommended. 

Syphilitic  Adenitis. — Syphilis  may  occasionally  cause 
a  marked  general  or  local  adenitis.  The  diagnosis  rests  on 
finding  other  manifestations  of  the  disease  and  on  rapid  im- 
provement by  antisyphilitic  treatment. 

DISEASES  OF  THE  THYMUS  GLAND. 

The  thymus  gland  increases  rather  rapidly  in  size  from 
birth  until  about  the  second  year,  and  more  slowly  until 
puberty.  Then  it  remains  about  the  same  size  until  about 
twenty-five  or  thirty,  when  it  atrophies  and  is  replaced  slowly 
by  fat  and  connective  tissue. 

In  Infantile  Atrophy  and  Marasmus. — The  thymus 
shows  marked  changes  macroscopically  and  microscopically. 
There  is  atrophy  of  the  gland  in  direct  proportion  to  the 
atrophy  of  the  body.  The  severe  cases  show  a  decrease  in 
the  lymphoid  cells  and  an  increase  in  the  connective  tissue. 

The  thymus  may  show  changes  in  syphilis  and  tubercu- 
losis, and  may  be  the  site  of  tumors  and  abscesses.  Hem- 
orrhages may  be  found  especially  in  children  who  have  been 
asphyxiated. 

It  is  hypertrophied  in  some  cases  of  acromegaly, 
gigantism,  chlorosis,  leukemia,  Hodgkin's  disease,  Graves' 
disease,  and  epilepsy.  Some  authors  state  that  it  is  also 
enlarged  in  infectious  diseases.  It  is  found  enlarged  in  thymic 
asthma  and  Paltauf's  status  thymicus.  It  is  atrophied  in 
atrophic  conditions,  rickets,  and  Bourneville  states  that  it  is 
present  in  only  27  per  cent,  of  idiots. 

Sudden  Death, — If  sufficiently  hypertrophied  the  thy- 
mus may  be  a  cause  of  sudden  death  in  infants.  The  child 
has  previously  been  well  or  slightly  cyanosed.  Usually  found 
dead.  There  is  marked  lividity  of  the  body,  and  there  may 
be  hemorrhages  into  the  gland.  The  gland  may  weigh  30 
to  45  gm.     Important  from  medicolegal   point  of  view. 

Thymic  Asthma. — When  the  hypertrophy  comes  on 
gradually ;  there  are  symptoms  of  intrathoracic  pressure. 
Pallor  and  edema  of  the  face,  suffusion  and  hemorrhages  into 
the  conjunctiva ;  cyanosis  of  lips  and  finger  tips ;  labored 


DISEASES  OF  THE  DUCTLESS  GLANDS.  251 

respiration  with  inspiratory  stridor.  This  last  may  be  due  to 
laryngeal  spasm  or  direct  pressure  on  the  trachea.  There  is  dul- 
ness  over  the  gland.  The  Rontgen  rays  have  given  remark- 
able results  in  some  cases.  If  this  is  not  successful,  the  gland 
may  be  entirely  or  partially  removed  by  surgical  operation. 

THE  ADRENALS. 

The  adrenals  are  relatively  larger  in  infants  than  in  adults. 

Hemorrhage  into  the  Adrenal.1 — May  be  seen  in 
the  newborn  in  the  course  of  infectious  diseases  and 
toxemias,  as  well  as  in  any  condition  of  general  congestion. 
The  symptoms  may  be  asthenic,  peritoneal,  or  nervous. 
These  vary  in  different  cases.  One  class  occurs  in  previously 
healthy  infants,  coming  on  suddenly  with  vomiting,  diarrhea, 
and  in  a  few  hours  a  petechial  eruption  and  generally  high 
fever.  Death  occurs  after  a  short  time.  (Purpura  fulminans.) 
These  cases  are  sometimes  mistaken  for  purpuric  small-pox, 
measles,  or  scarlet  fever.  There  may  be  nothing  to  suggest 
an  infectious  disease  in  some  of  these  cases. 

ADDISON'S  DISEASE. 

This  is  very  rarely  seen  in  early  life.  The  lesion  is 
usually  a  tuberculosis  of  the  adrenal  or  degenerative  changes 
in  the  abdominal  sympathetic  ganglia.  The  symptoms  are 
bronzing  of  the  skin  and  pigmentation  of  the  mucous  mem- 
branes. There  are  great  weakness,  cachexia,  and  great  irrita- 
bility of  the  stomach.  The  pulse  is  rapid  and  weak.  Death 
may  take  place  from  tuberculosis,  asthenia,  coma,  or  convul- 
sions. The  diagnosis  is  from  arsenical  pigmentation  and 
malarial  cachexia.  The  treatment  is  along  general  tonic 
lines.  Adrenal  tablets  or  extract  should  be  tried,  the  effect 
closely  watched,  and  the  dose  regulated  accordingly.  Recovery 
is  the  exception. 

THE  SPLEEN. 

The  Normal  Spleen. — The  spleen  lies  with  the  upper 
border  on  about  the  ninth  rib,  and  the  lower  about  the  elev- 
enth rib.     Posteriorly  it  extends  to  the   posterior  axillary 

1  Dudgeon,  American  Journal  of  the  Medical  Sciences,  February,  1904. 


252  DISEASES  OF  INFANTS  AND  CHILDREN. 

line,  and  anteriorly  to  about  the  midaxillary  line.  It  does  not 
normally  pass  a  line  drawn  from  the  left  nipple  to  the  end  of 
the  eleventh  rib.  The  splenic  dulness  corresponds  to  the 
above.  It  is  often  obliterated,  however,  by  abdominal  tym- 
pany due  to  inflated  stomach  or  intestines.  An  overloaded 
intestine  may  give  rise  to  dulness  and  simulate  an  enlarged 
spleen. 

Enlargement  of  the  Spleen. — If  the  spleen  is  en- 
larged it  can  usually  be  made  out  by  palpation.  A  spleen 
which  extends  beyond  the  edge  of  the  ribs  may  be  looked 
upon  as  enlarged.  A  pleural  effusion  may  push  a  normal 
spleen  downward. 

An  enlarged  spleen-  during  inspiration  moves  downward 
and  to  the  right,  in  the  direction  of  the  right  iliac  crest.  If 
the  liver  is  enlarged  the  liver  and  splenic  dulness  may  be 
continuous.  The  same  is  true  when  there  is  an  effusion  in 
Traube's  semilunar  space.  In  a  good  light,  with  the  abdomi- 
nal walls  properly  stretched,  an  enlarged  spleen  can  often  be 
seen  to  move  up  and  down.  There  may  be  enlarged  veins 
seen  in  the  splenic  area,  and  over  a  very  large  spleen 
there  may  be  a  blowing  murmur  like  that  over  a  pregnant 
uterus. 

An  enlarged  spleen  is  seen  in  almost  all  acute  infectious 
fevers.  It  is  especially  marked  in  typhoid  fever  and  malaria, 
only  occasionally  enlarged  in  cerebrospinal  fever  and  rarely 
in  mumps.  In  almost  all  the  chronic  diseases  of  early  life 
the  spleen  is  enlarged.  In  active  rickets,  in  leukemia  and 
pseudoleukemia  and  Hodgkin's  disease  it  is  constantly 
enlarged.     It  is  usually,  but  not  always,  enlarged  in  syphilis. 

Amyloid  Spleen. — (Sago  Spleen.) — This  is  large,  thick, 
and  smooth.  It  is  seen  in  long-standing  suppurations, 
especially  of  the  bones ;  also  in  chronic  pulmonary  tubercu- 
losis and  in  old  cases  of  syphilis.  The  liver  is  also  enlarged, 
and  there  is  a  cachectic  condition.  Amyloid  changes  are  not 
as  frequent  as  formerly  owing  to  the  improved  surgical  treat- 
ment of  suppurative  diseases. 

Chronic  Passive  Congestion  of  the  Spleen. — This 
follows  stasis  in  the  portal  and  splenic;  vessels.     It  is  seen 


DISEASES  OF  THE  DUCTLESS  GLANDS.  253 

in  diseases  of  the  liver,  especially  cirrhosis,  from  lesions  in 
the  lungs,  which  obstruct  the  blood-current,  and  especially  in 
acquired  or  congenital  heart  disease.  The  liver  is  always 
enlarged  at  the  same  time,  except  when  the  spleen  vessels  are 
alone  involved. 

New  Growths. — These  are  rare  in  infancy  and  child- 
hood. A  new  growth  may  be  suspected  if  the  surface  of  the 
spleen  is  nodular.  This  may  be  tuberculosis,  sarcoma,  car- 
cinoma, syphilis,  cysts,  or  parasites.  Tuberculosis  is  the 
most  frequent. 

Splenitis. — Splenitis  may  occur  from  extension  of  a 
neighboring  inflammation.    The  diagnosis  is  always  doubtful. 

Perisplenitis. — This  may  follow-  injuries,  hemorrhagic 
infarcts,  or  be  caused  by  extension,  tuberculosis,  or  syphilis. 
A  friction-rub  can  often  be  heard.  The  spleen  may  become 
adherent  and  immovable  in  cases  of  long  standing. 

Floating  Spleen, — This  is  occasionally  seen  as  a  con- 
genital condition.  The  diagnosis  is  made  from  its  shape  and 
the  presence  of  tympany  over  the  area  of  splenic  dulness.  It 
must  be  differentiated  from  tumors  of  the  same  size  and  from 
fecal  masses. 

PRIMARY  SPLENOMEGALY  (Gaucher).1 

A  rare  form  of  splenic  enlargement  without  any  apparent 
cause.  There  is  a  hyperplasia  of  the  endothelial  cells  of  the 
spleen  and  of  the  connective  tissue  of  the  liver.  The  disease 
is  slow  and  progressive.  It  begins  between  the  second  and 
seventh  year.  There  are  anemia  and  symptoms  referable  to 
the  enormous  spleen.     The  prognosis  is  bad. 

DYSTROPHIA  ADIPOSOGENITALIS. 

Frohlich's  syndrome  is  due  to  inactivity  of  the  pituitary 
gland,  characterized  by  obesity  and  a  lack  of  development 
of  the  genital  organs,  an  increased  assimilation  limit  for  carbo- 
hydrates,  often  dry  skin,  subnormal  temperature,  and  lack 
of  development  of  the  hair.  Pituitary  gland  administrations 
have  been  administered  occasionally  with  benefit. 

1  Bovaird,  American  Journal  of  the  Medical  Sciences,  October,  1900. 


254 


DISEASES  OF  INFANTS  AND  CHILDREN. 


THE  URINE  IN  INFANCY  AND  CHILDHOOD. 

Character  of  the  Urine. — The  urine  of  the  newborn 
is  highly  colored,  stains  the  napkin,  and  often  leaves  deposits 
of  urates  or  uric  acid. 

Later  the  urine  is  pale  and  often  contains  considerable 
mucus,  which  makes  it  cloudy. 

The  specific  gravity  varies,  but  is  high  during  the  first  two 
days,  lowest  from  the  fourth  to  the  sixth  day,  and  gradually 
increases  to  puberty. 

Hyaline,  and  more  rarely  granular,  casts  may  be  found. 
Phosphates,  chlorids,  and  sulphates  all  increase  with  age. 

Albumin  may  be  present  in  early  infancy. 

Sugar,  usually  lactose,  may  sometimes  be  found  in  early 
infancy. 

Collecting  the  Urine. — For  male  infants  place  the 
penis  and  scrotum  in  a  large  condom  and  secure  in  place  with 
a  tape.  For  girls  a  small  cup  may  be  secured  over  the 
vulva.  This  is  rarely  successful.  The  child  may  be  placed 
on  a  chamber  immediately  on  waking  or  it  may  be  catheterized. 


Age. 

Quantity. 

Specific 
gravity. 

Urea,  daily 
quantity. 

Ratio  uric 
acid  to  urea. 

Grams. 

Ounces. 

Grams. 

First  24  hours  .... 

0-60 

0-2  | 

3^-3  ) 

1.010-1.012 

0.076-0.114 

1:14 

Second  24  hours     .  . 

10-90 

) 

[ 

0.140-0.660 

3  to  6  days 

90-250 

3-8 

1.004-1.008) 

7  days  to  2  months    . 

150-400 

5-13) 

[ 

1.004-1.010 

0.90-1.40 

1 :  60-80 

2  to  8  months  .... 

210-500 

7-16  j 

6  months  to  2  years  . 

250-600 

8-20 

1.006-1.012 

1 :  60-80 

2  to  5  years 

500-800 

16-26) 

[ 

1.008-1.016 

13.09-14.01 

1 :  50-70 

5  to  8  years 

600-1200 

20-40 J 

1 
1.012-1.020  j" 

16.05-21.03 

1 :  45-60 

8  to  14  years 

1000-1500 

32-48 

Quantity. — Relatively  more  urine  is  passed  by  infants 
than  by  adults.  Infants  micturate  very  frequently,  hourly 
or  oftener,  while  they  are  awake,  and  every  two  or  three 


THE   URIXE  IN  INFANCY  AXD   CHILDHOOD.       255 

hours  while  asleep.  Later  the  urine  is  held  several  hours 
without  difficulty.  Well-trained  infants  control  the  bladder 
at  two  or  three  years  of  age.  Nervous  or  untrained  children 
may  wet  themselves  for  several  years.  Sometimes  an  infant 
does  not  void  any  urine  for  ten  or  twelve  hours,  and  then 
after  passing  a  very  large  quantity  returns  to  its  former 
habits. 

The  table  on  the  preceding  page  gives  the  quantity  and 
other  facts  about  the  urine.  It  has  been  compiled  from 
various  authorities. 

FUNCTIONAL  ALBUMINURIA.1 
(Physiologic  or  Cyclic  Albuminuria.) 

Definition, — Albuminuria  occurring  without  any  de- 
monstrable signs  or  symptoms  of  disease. 

Ktiology. — It  is  most  frequently  seen  in  boys  between 
five  and  fifteen  years  of  age.  It  may  be  present  in  the  urine 
excreted  while  the  individual  is  in  the  erect  posture  (ortho- 
static albuminuria)  and  absent  while  he  is  lying  down,  and 
consequently  albumin  is  not  present  in  the  urine  passed  early 
in  the  morning  on  rising.  It  may  also  apparently  be  due  to 
exercise,  fatigue,  indigestion,  and  too  much  protein  food. 

Symptoms. — There  are  no  symptoms.  The  patients 
may  be  well  or  suffer  from  other  diseases.  The  albumin  is 
usually  discovered  accidentally. 

Diagnosis. — Sometimes  difficult.  Absence  of  other 
signs  of  disease,  absence  of  casts,  passing  urine  free  from 
albumin  at  night  or  in  the  early  morning,  and  high  specific 
gravity  are  the  most  important  points. 

Prognosis. — If  albumin  is  not  constantly  present  and 
is  in  small,  not  increasing,  quantities,  the  outlook  is  good. 
If  it  is  increasing  and  is  constant,  actual  disease  of  the  kid- 
ney is  probably  present. 

Treatment. — General  hygiene  ;  proper  diet ;  relieve  the 
indigestion.  Alkaline  mineral  waters  are  sometimes  used. 
Iron  should  be  given  if  anemia  is  present. 

1  Rachford,  "Albuminuria,"  Archives  of  Pediatrics,  August,  1908.  Suth- 
erland, "  Orthostatic  Albuminuria,"  Amer.  Jour.  Med.  Sci.,  August,  1903. 


256  DISEASES  OF  INFANTS  AND  CHILDREN. 

HEMATURIA. 

(Blood  in  the  Urine.) 

The  red  blood-cells  may  be  demonstrated.  Is  due  to  in- 
jury, nephritis,  new  growths,  stone  in  kidney,  ureter  or 
bladder,  tumor  in  the  bladder,  hemorrhagic  disease  of  the 
newborn,  scurvy,  purpura,  and  similar  conditions ;  various 
infections,  as  malaria  and  scarlet  fever ;  and  to  the  adminis- 
tration of  drugs,  as  chlorate  of  potassium  and  quinin. 

Diagnosis.  —  Best  by  microscopic  examination.  It 
should  be  suspected  where  the  urine  is  dark  and  cloudy.  If 
from  the  urethra,  the  urine  first  passed  is  cloudy ;  if  from  the 
bladder,  the  blood  is  often  with  the  last  urine  passed ;  if 
from  the  kidney,  the  blood  is  thoroughly  mixed  with  the 
urine. 

Treatment. — This  depends  on  the  cause.  Chronic  cases 
may  be  given  alum  water  or  Rockbridge  spring  water. 

HEMOGLOBINURIA.1 

Blood  pigment  is  found  in  the  urine  with  a  few  or  no 
blood-cells.  It  may  be  seen  in  epidemic  hemoglobinuria 
(Winckel's  disease),  in  acute  infections  (as  malaria  and 
typhoid  fever),  purpura,  poisons  (chlorate  of  potassium  or 
carbolic  acid),  from  the  absorption  of  hemorrhagic  eifusions, 
and  there  is  a  paroxysmal  hemoglobinuria  met  with  in  child- 
hood. 

GLYCOSURIA. 

(Sugar  in  the  Urine.) 

May  be  seen  in  young  infants  otherwise  in  good  health. 
The  sugar  in  these  cases  is  usually  lactose  (milk  sugar).  It 
may  occur  from  eating  excessive  amounts  of  sugar  (alimen- 
tary glycosuria)  ;  the  kind  of  sugar  given  will  be  found  in 
the  urine,  as  cane  sugar,  milk  sugar,  or  grape  sugar.  Gly- 
cosuria is  one  of  the  symptoms  of  diabetes. 

1  Herman,  Archives  of  Pediatrics,  February,  "903,  p.  105.  Guthrie, 
"  Hematuria,"  Lancet,  May  3,  1903,  p.  1243. 


THE    URINE  IX  INFANCY  AND   CHILDHOOD.       257 

PYURIA. 

Pus  in  the  urine  usually  comes  from  the  pelvis  or  the 
kidney,  but  may  come  from  inflammation  of  any  part  of  the 
genitourinary  tract  or  from  rupture  of  abscess  into  it.  The 
treatment  depends  upon  the  cause.  Urotropin  is  useful.  It 
may  be  given  in  from  1  to  5  gr.  doses  several  times  a  day. 

LITHURIA. 

Excessive  amounts  of  urea  and  uric  acid  in  the  urine. 
Uric  acid  is  derived  from  the  destruction  of  the  cell  nuclei. 
The  quantity  for  twenty-four  hours  must  be  estimated. 
Urine  of  low  specific  gravity  from  which  amorphous  urates 
are  deposited  may  be  regarded  as  containing  excessive 
amounts  of  uric  acid. 

The  symptoms  of  the  condition  are  of  a  general  nature, 
and  may  be  regarded  as  an  indication  of  disturbed  metab- 
olism. It  is  seen  in  anemia,  chorea,  rheumatism,  malnu- 
trition, etc.  Where  crystals  of  uric  acid  are  deposited  from 
highly  colored  urine  of  high  specific  gravity  the  solvent 
power  of  the  urine  for  uric  acid  is  diminished.  It  may  be 
associated  with  digestive  disturbances. 

Treatment. — This  depends  on  the  existing  conditions ; 
where  otherwise  allowable,  exercise  in  the  open  air  and  alka- 
line mineral  waters,  as  Vichy,  should  be  ordered.  Holt 
advises  cutting  off  sugars,  reducing  the  starchy  food,  and 
giving  a  diet  rich  in  protein. 

INDICANURIA. 

The  presence  of  indican  in  the  urine.  A  trace  may  be 
found  in  normal  urine.  A  strong  reaction  is  found  in  urine 
of  children  suffering  with  suppurative  conditions,  as  empyema, 
constipation,  and  tuberculosis.  Also  seen  in  intestinal  fer- 
mentation and  chronic  intestinal  indigestion. 

The  treatment  consists  in  removing  the  cause,  diminishing 
intestinal  putrefaction,  and  giving  a  milk  diet. 

17 


258  DISEASES  OF  INFANTS  AND  CHILDREN 

ACETONURIA. 

The  presence  of  acetone  in  the  urine  is  rather  a  frequent 
occurrence,  and  small  amounts  may  sometimes  be  found  in 
health.  It  is  found  in  a  number  of  conditions  which  show 
no  symptoms  of  acidosis,  among  these  may  be  mentioned  the 
excessive  ingestion  of  fat,  starvation,  high  fever,  gastric 
ulcer,  malignant  disease,  and  many  others.  There  is  another 
group  of  cases  where  the  symptoms  of  acid  poisoning  may  be 
noted  in  connection  with  other  diseases,  as  in  diabetes,  intra- 
cranial disease,  toxic  forms  of  gastro-intestinal  disturbance, 
diarrhea,  sepsis,  intestinal  obstruction,  acute  peritonitis,  and 
due  to  the  influence  of  certain  drugs  used  in  poisonous  doses, 
as  morphin  and  salicylate  of  sodium.  There  is  a  third 
group  of  uncomplicated  cases,  such  as  are  seen  following  the 
administration  of  anesthetics  in  recurrent  or  cyclic  vomiting. 

DIACETURIA. 

The  presence  of  diacetic  acid  in  the  urine.  This  is  found 
in  the  same  conditions  as  acetone.  It  is  quite  common  in 
high  fevers  and  disappears  when  the  fever  falls.  It  may 
precede  diabetic  coma. 

Where  acid  autointoxication  is  present  bicarbonate  of 
soda  in  rather  large  doses  is  indicated. 

ANURIA* 

An  absence  of  secretion  of  urine.  This  may  be  seen  in 
infants  without  any  apparent  cause.  As  long  as  there  are 
no  other  symptoms  there  is  no  danger.  It  may  be  caused 
by  uric-acid  infarcts.  The  treatment  is  the  same  as  in  dimi- 
nution of  urine. 

DIMINUTION  OF  URINE. 

This  may  occur  from  excessive  sweating,  fever,  diminished 
ingestion  of  fluid,  etc. 

Treatment. — Hot  applications  over  the  kidneys,  the  ad- 


THE   URINE  IN  INFANCY  AND  CHILDHOOD.      259 

ministration  of  hot  water  and  of  sweet  spirits  of  niter  with 
or  without  citrate  of  potassium. 

DIABETES  INSIPIDUS. 

(Polyuria.) 

Definition. — A  chronic  disease  characterized  by  great 
thirst  and  the  excretion  of  large  quantities  of  urine. 

Etiology. — The  disease  is  rare.  It  usually  begins  under 
ten  years  of  age.  It  may  occur  in  families.  It  may  follow 
injuries  about  the  head  or  brain  lesions. 

Pathology. — Obscure.  It  is  usually  classed  as  a  neu- 
rosis. 

Symptoms. — The  passing  of  large  quantities  of  urine 
(from  2  to  10  liters  daily),  great  thirst,  and  frequently 
nervous  symptoms,  as  neuralgia,  headache,  and  other  motor 
disturbances,  are  the  principal  symptoms.  The  urine  is  clear 
and  contains  neither  grape  sugar  nor  albumin. 

Diagnosis. — From  diabetes  by  the  absence  of  grape 
sugar.  From  interstitial  nephritis  by  careful  study  of  urine 
and  symptoms. 

Prognosis. — As  regards  cure,  usually  bad.  A  few  cases 
recover  spontaneously  or  with  treatment. 

Treatment. — Good  hygiene  ;  out-of-door  life  ;  good,  well- 
balanced  diet.  Restrict  the  amount  of  fluids  taken.  Numer- 
ous drugs  have  been  recommended  ;  atropin  or  belladonna, 
arsenic,  and  bromids  are  most  useful ;  antipyrin  or  ergot  may 
be  tried. 

Diseases  of  the  Kidneys, 
malformations  and  malpositions  of  the  kidney.1 

Only  one  kidney  may  be  present,  the  other  being  rudi- 
mentary or  entirely  absent.  Both  kidneys  may  be  fused 
together — the  so-called  "  horseshoe  kidney."  Cystic  degen- 
eration of  the  kidney  is  sometimes  seen  affecting  one  or  both 

1  Anders,  "  Congenital  Single  Kidney,"  American  Journal  of  Medical  Sci- 
ences, March,  1910,  p.  314. 


260  DISEASES  OF  INFANTS  AND  CHILDREN. 

kidneys.  The  kidney  substance  is  replaced  by  cysts  wnich 
may  reach  a  considerable  size.  There  are  no  symptoms 
referable  to  the  kidneys,  but  sometimes  the  enlarged  kidney 
may  be  felt. 

Hydronephrosis. — The  bladder  may  be  enlarged,  the 
ureters  and  the  pelvis  of  the  kidneys  dilated.  There  is 
usually — but  there  may  not  be — some  obstruction  to  the  out- 
flow of  urine  causing  this.  The  deformity  may  be  unilateral 
or  bilateral.     An  abdominal  tumor  may  be  felt  in  some  cases. 

There  may  be  malpositions  of  one  or  both  kidneys,  and 
movable  kidneys  may  occasionally  be  met  with.  There  may 
be  additional  ureters. 

URIC-ACID  INFARCTIONS. 

Deposits  of  uric  acid  or  of  urates  in  the  tubules  of  the 
kidneys  are  common  during  the  first  few  weeks  of  life.  They 
may  or  may  not  cause  symptoms.  Diminished  urine  or 
anuria,  pain  on  urinating,  and  priapism  are  symptoms  which 
may  be  met  with.  The  urine  stains  the  napkin,  and  the 
crystals  may  sometimes  be  demonstrated  upon  it. 

Hot  water  to  drink,  together  with  citrate  of  potassium 
(1  gr.  every  two  hours),  usually  gives  prompt  relief. 

HYPEREMIA  OR  CONGESTION  OF  THE  KIDNEY. 
ACUTE    CONGESTION. 

Etiology. — From  exposure  to  cold ;  the  ingestion  of 
drugs,  as  turpentine,  cantharides,  etc. ;  from  injuries  or  fevers. 

Symptoms. — The  urine  is  scanty,  highly  colored,  of 
high  specific  gravity,  and  may  contain  small  quantities  of 
blood,  albumin,  and  tube  casts.  There  may  be  headache, 
backache,  etc.  The  condition  may  pass  off  in  a  day  or  two 
or  may  precede  an  acute  nephritis. 

Treatment. — Rest  in  bed;  milk  diet;  hot  packs,  hot 
steam  baths,  hot  applications  or  dry  cups  over  the  kidneys ; 

saline  cathartics. 
17 


THE   tJBINE  IN  INFANCY  AND  CHILDHOOD.      261 

CHRONIC    CONGESTION   OF  THE  KIDNEY. 
( Passive   Hyperemia.  I 

Etiology. —  From  impeded  circulation,  most  frequently 
from  chronic  diseases  of  heart  or  lungs,  but  also  from  any- 
thing which  prevents  the  return  circulation  of  the  kidneys, 
a<  tumors  or  enlarged  glands  pressing  upon  the  veins. 

Pathology. — The  kidneys  are  enlarged  and  of  dark-red 
color.     The  capillaries  are  distended  with  blood. 

Symptoms. — The  urine  is  scanty,  dark,  and  of  high 
specific  gravity.  It  may  contain  blood,  albumin,  and  hyaline 
casts.  When  dependent  upon  general  stasis,  other  symptoms, 
as  edema  and  cyanosis,  may  be  present. 

Treatment. — The  primary  condition  should  be  treated. 
In  addition,  rest  in  bed,  milk  diet,  and  diuretics.  Citrate  of 
potassium,  infusion  of  digitalis,  caffeiu,  calomel,  or  sweet 
spirits  of  nitre,  diuretin. 

INFLAMMATION  OF  THE  KIDNEY.1 

The  student  is  sometimes  confused  by  the  numerous  terms 
applied  to  various  conditions.  The  simplest  classification  is 
into  acute  nephritis  and  chronic  parenchymatous  nephritis  and 
chronic  interstitial  nephritis. 

Acute  nephritis. 

(Acute  Bright's  Disease;  Acute  Tubular  Nephritis;  Acute  Parenchym- 
atous Nephritis;  Acute  Desquamative  Nephritis;  Acute  Diffuse 
Nephritis,  etc*) 

Definition. — An  acute  inflammation  of  the  kidney. 

Etiology. — The  principal  causes  are:  (1)  Infectious  dis- 
eases, especially  scarlet  fever  and  diphtheria ;  (2)  exposure 
to  cold  and  wet;  (3)  toxic  agents,  such  as  turpentine,  chlorate 
of  potassium,  and  carbolic  acid. 

Pathology. — There  are  changes  in  the  vascular,  epithelial, 
and  interstitial  tissues.  These  may  vary  in  intensity,  and  this 
has  led  to  the  numerous  classifications.  If  the  entire  kidney 
1  Morse,  American  Medicine,  April  5,  1905,  p.  551. 


262  DISEASES  OF  INFANTS  AND  CHILDREN. 

is  more  or  less  uniformly  involved  it  is  called  a  diffuse 
nephritis ;  if  the  tubules  are  chiefly  affected,  parenchymatous 
nephritis ;  if  the  glomeruli  are  the  seat  of  marked  changes, 
as  in  scarlatina,  glomerulonephritis.  In  children,  after  fevers, 
the  interstitial  tissue  may  be  the  seat  of  extensive  changes. 

The  kidney  may  not  present  any  marked  naked-eye  change, 
or  it  may  be  enlarged  in  the  early  stages,  red  and  dripping 
blood,  the  cortex  swollen  and  turbid,  pyramids  intensely 
congested.     Later  the  kidney  may  be  paler. 

Histology. — The  tubular  cells  show  cloudy  swelling, 
and  may  be  desquamated,  and  the  tubes  may  be  blocked  by 
hyaline  or  granular  casts.  The  vessels  are  engorged.  The 
interstitial  tissue  is  frequently  infiltrated  with  cells  (leuko- 
cytes and  plasma  cells). 

Symptoms. — Nephritis  may  be  primary  or  secondary  to 
some  other  disease. 

Primary  Nephritis. — In  Infants. — Sudden  onset,  vomiting, 
frequently  diarrhea,  high  fever,  nervous  symptoms,  dulness 
and  apathy,  marked  anemia,  sometimes  edema.  The  outlook 
is  bad;  the  majority  of  the  cases  prove  fatal. 

In  Older  Children.— Onset  less  often  sudden,  moderate 
fever,  vomiting,  anemia,  often  edema.  Prognosis  is  better 
than  in  infants. 

Secondary  Nephritis. — Comes  on  usually  at  the  height  of 
the  febrile  stage  of  the  primary  disease.  It  may  be  over- 
looked. There  is  often  an  increase  in  temperature,  headache, 
vomiting,  sometimes  edema.  The  nephritis  of  scarlet  fever 
usually  comes  on  late — at  the  third  or  fourth  week  of  the 
disease.     There  is  fever,  with  the  edema  always  marked. 

The  Urine. — The  urine  is  at  first  scanty  or  even  suppressed. 
It  is  dark,  of  high  specific  gravity,  contains  blood,  albumin, 
tube  casts,  and  desquamated  epithelium.  The  daily  amounts 
of  urea  are  diminished.  Later  the  urine  becomes  freer, 
lighter  in  color,  and  of  lower  specific  gravity. 

Diagnosis. — On  the  symptoms  and  examination  of  the 
urine. 

Nephritis  should  be  suspected  whenever  there  is  fever 
with  marked  pallor.     The  disease  is  often  overlooked. 


THE   URINE  IN  INFANCY  AND  CHILDHOOD.       263 

Prognosis. — Under  three  years  the  prognosis  is  grave. 
If  the  child  does  not  die  in  the  acute  attack  it  is  liable  to  have 
evidence  of  chronic  nephritis  later  in  childhood.  In  older 
children  the  outlook  is,  on  the  whole,  much  more  favorable. 
Death  may  occur  from  edema  of  the  lungs,  uremia,  or  ex- 
haustion.    The  disease  may  become  chronic. 

Prophylaxis. — In  all  acute  fevers,  but  especially  scarlet 
fever,  bland  unirritating  diet,  principally  of  milk  and  carbo- 
hydrates, should  be  given.  Protect  from  cold  and  injudi- 
cious drugging. 

Treatment. — Rest  in  bed  ;  keep  warm.  Sponge  or 
warm  or  vapor  baths  to  promote  sweating.  Hot  wet-packs 
are  useful.  Dry  cups  or  warm  applications  over  the  kidneys. 
Saline  cathartics.  As  long  as  the  urine  is  very  scanty  or 
suppressed  and  water  is  excreted  with  difficulty,  the  amount 
of  fluid  given  should  be  rather  limited.  Citrate  of  potassium 
may  be  given  with  alkaline  mineral  waters.  If  there  are 
any  symptoms  of  uremia,  stimulants  are  indicated;  nitro- 
glycerin is  useful.  Nervous  symptoms  are  best  controlled 
by  chloral  or  morphin.  Xitroglycerin  may  be  tried  when 
there  is  high  pulse  tension,  vomiting,  delirium,  and  high 
temperature.  Bleeding  may  be  tried  where  uremia  threatens. 
From  two  to  five  ounces  of  blood  may  be  withdrawn,  accord- 
ing to  circumstances.  This  should  be  followed  by  sub- 
cutaneous injections  of  normal  salt  solution.  Rectal  enemata 
of  hot  salt  solution  may  cause  free  diuresis.  As  soon  as  the 
diuresis  becomes  freer,  hot  (105°  F.)  saline  injections  into 
the  rectum  should  be  given  several  times  a  day.  Increased 
amounts  of  alkaline  mineral  waters  or  imperial  drinks  (see 
formulas)  should  be  given. 

The  diet  should  be  milk  diluted  with  mineral  waters  or 
thin  gruels,  buttermilk,  koumiss,  whey,  junket,  and  farina- 
ceous gruels.  Meat  should  not  be  given  until  convalescence 
is  well  established.  Where  anemia  is  severe,  solid  food  may 
be  added  cautiously,  watching  the  temperature.  The  diet 
must  be  carefully  supervised  for  a  long  time.  If  there  is 
edema,  a  salt-free  diet  may  be  tried. 


264 


DISEASES  OF  INFANTS  AND   CHILDREN. 


Chronic  Nephritis.1 

This  may  be  either  parenchymatous  or  interstitial,  or  a 
combination  of  both. 

Etiology. — It  is  rare  in  childhood.  It  may  be  seen 
after  acute  infections,  especially  scarlet  fever  or  prolonged 
suppurative  diseases.  It  may  occur  in  the  course  of  chronic 
tuberculosis,  hereditary  syphilis,  or  chronic  heart  disease.  It 
may  be  seen  in  gouty  children  and  in  those  rare  cases  of 
early  arteriosclerosis  of  obscure  origin. 

Pathology. — In  chronic  parenchymatous   nephritis  the 


Fig.  65.— Chronic  parenchymatous  nephritis. 

organs  are  referred  to  as  "  large  white  kidney."  The  kidney 
may  be  red,  however,  and  show  very  little  change.  The  his- 
tologic changes  are  cloudy  swelling  of  the  epithelial  cells,  or 
they  may  be  fatty  or  granular.  The  cells  are  desquamated 
and  the  tubules  contain  casts  and  granular  material.  In 
chronic  interstitial  nephritis  the  change  is  the  same  as  in 
adults.  The  kidney  is  small  and  granular,  with  adherent 
capsules,  thin  cortex,  and  the  histologic  changes  are  an  in— 

Cotton,  Archives  of  Pediatrics,  April,  1904,  p.  241.  Sawyer,  "Inter- 
stitial Nephritis,"  Birmingham  Medical  Review,  August  and  September, 
2903. 


THE   URINE  IN  INFANCY  AND   CHILDHOOD.       265 

crease  of  the  connective  tissue,  arteriosclerosis,  and  atrophy 
of  the  parenchyma. 

Symptoms. — Chronic      Parenchymatous     Nephritis. — 


Fir,.  66.— Showing  edema  and  ascites  in  chronic  parenchymatous  nephritis  in  a 

child  of  five  years. 

Edema,  effusion  into  the  serous  cavities,  with  digestive  dis- 
turbances, are  the  most  marked  symptoms.  There  are  also 
anemia,  headache,  occasional  vomiting,  or  diarrhea.  There 
may  be  enlargement  of  the  heart  with  murmurs  and  accentua- 
tion of  the  aortic  sound. 

The  Urine. — The  urine  varies  from  time  to  time.  It  con- 
tains varying  amounts  of  albumin  and  granular  and  fatty 
casts.  The  specific  gravity  is  high  and  the  quantity  normal 
or  less  than  normal. 

Prognosis. — The  outlook  is  not  very  good.  The  disease 
lasts  from  two  to  four  years.  These  patients  frequently  die 
of  intercurrent  diseases. 

Chronic  Interstitial  Nephritis.1 — This  form  is  very  rare  in 

children.     Syphilis   is  the  most  frequent  cause.     Edema  is 

rarely  marked.     The  disease  begins  gradually  with  headache, 

neuralgia,  and  attacks  of  dyspepsia.     There  are  high  arterial 

tension   and  arteriosclerosis.     Large  quantities  of  pale  urine 

with  a  low  specific  gravity  are  passed.     Small  quantities  of 

albumin  and  an  occasional  tube  cast  may  be  present.     The 

outlook  in  this  form  is  always  grave.     The  disease  runs  a 

very  chronic  course. 

*W.  P.  Herringham,  "  Nephritis,  Chronic,  Prognosis  of,  in  the  Young/' 
Edinburgh  Medical  Journal,  July,  1906,  p.  24. 


266  DISEASES  OF  INFANTS  AND  CHILDREN. 

Diagnosis. — The  urine  should  be  examined  in  all  cases 
of  headache,  pallor,  edema,  and  high  arterial  tension. 

Treatment. — This  is  much  the  same  as  in  adults,  and 
requires  attention  and  experience.  The  amount  of  exercise 
should  be  regulated  to  the  child's  condition,  and  many  cases 
should  be  confined  to  bed.  A  daily  warm  bath  is  of  use. 
The  child  should  be  protected  from  cold,  and  a  warm,  dry 
climate  is  best  where  circumstances  allow  a  change.  The 
diet  should  consist  largely  of  milk,  cereals  (oatmeal  ex- 
cepted), bread  and  butter,  and  vegetables  (legumes  spar- 
ingly, if  at  all).  Meat  should  be  given  according  to  circum- 
stances, not  over  once  a  day,  sometimes  only  every  other  day. 
Eggs  should  be  used  sparingly  as  a  rule.  A  salt-free  diet 
may  often  be  used  to  advantage,  especially  where  there  is  a 
tendency  to  edema.  (See' Diet  in  Health  and  Disease,  fourth 
ed.,  p.  543.)  Iron  is  of  value  in  most  cases,  and  the  liquor  ferri 
et  ammonia?  aoetatis  a  good  preparation  to  use  in  these  cases. 

AMYLOID  DEGENERATION  OF  THE  KIDNEY. 
(Waxy  Kidney?  Lafdaceous  Kidney.) 

Etiology. — This  is  seen  in  long-standing  suppurations, 
especially  of  the  bones,  and  in  syphilis  and  chronic  tubercu- 
losis. 

Pathology. — The  kidney  is  enlarged,  firm,  and  pale.  On 
section  it  has  a  translucent  appearance.  This  turns  mahog- 
any brown  on  being  treated  with  Lugol's  solution.  The 
liver  and  spleen  are  also  affected.  Amyloid  changes  are  less 
common  than  formerly,  owing  to  the  more  radical  treatment 
of  suppurating  foci. 

Symptoms. — There  are  anemia  and  general  ill  health  from 
the  original  disease.  The  liver  and  spleen  are  enlarged. 
The  cachexia  is  sometimes  called  "  alabaster  cachexia." 

The  Urine. — The  quantity  is  increased,  pale,  of  low  specific 
gravity,  and  contains  large  quantities  of  albumin.  There  are 
casts  giving  amyloid  reaction. 

Diagnosis. — The  history,  the  cachexia,  increased  quan- 
tity of  urine  with  small  albuminuria,  together  with  the  en- 
larged liver  and  spleen,  usually  render  diagnosis  possible. 


THE  URINE  IN  INFANCY  AND  CHILDHOOD.       267 

Prognosis. — Grave  unless  the  predisposing  cause  can  be 
removed  early. 

Treatment. — Along  general  lines,  both  hygienic  and 
tonic.  The  main  thing  is  the  treatment  of  the  original 
disease. 

NEW  GROWTHS  IN  THE  KIDNEY.1 

Tumors  of  the  kidney  in  children  are  usually  malignant. 
The  majority  of  these  are  sarcomata.  The  growth  is  primary 
in  the  kidney.  The  growth  usually  starts  in  the  pyramids, 
which  is  just  the  opposite  of  the  adult  type,  which  starts  in 
the  cortex.  The  pelvis  may  be  the  starting-point  or  it  may 
begin  in  the  adrenal  or  an  adjacent  lymph  gland.  The  tumor 
may  reach  an  enormous  size.  Sarcoma  is  most  frequently 
seen  in  the  left  kidney. 

Symptoms. — The  tumor,  cachexia,  and  often  hematuria. 
There  may  be  pressure  symptoms,  depending  on  the  size  of 
the  growth. 

Diagnosis. — Almost  all  tumors  in  the  abdomen  under 
ten  yrears  are  sarcoma.  Benign  growths  usually  grow  slowly, 
while  these  malignant  ones  grow  rapidly. 

Treatment. — Removal  by  surgical  operation. 

PYELITIS.2 

Definition. — Inflammation  of  the  pelvis  of  the  kidney, 
which  is  often  associated  with  inflammation  of  the  kidney, 
pyelonephritis ;  or  of  the  bladder,  pyelocystitis ;  or  it  may 
lead  to  accumulation  of  pus  in  the  kidney,  pyelonephrosis. 

Etiology. — (1)  Renal  calculi,  (2)  malformations,  (3) 
tuberculosis,  (4)  from  extension  of  an  inflammation,  (5) 
pyemia,  (6)  secondary  to  cystitis. 

Symptoms. — Pain,  and  often  swelling  of  the  kidney, 
chills,  irregular  fever,  sweats,  leukocytosis,  acid  urine  with 
blood,  pus,  desquamated  epithelium  from  the  pelvis  of  the 
kidney,  mucus,  and  albumin. 

1  Strong,  Archives  of  Pediatrics,  May,  1903,  p.  321. 

2  Fischer,  Archives  of  Pediatrics,  January,  1901,  p.  13.  Thomson,  "Acute 
Pyelitis,"  Scottish  Medical  and  Surgical  Jouracd,  July,  1902. 


268  DISEASES  OF  INFANTS  AND  CHILDREN. 

Diagnosis. — Acid  urine  with  pus  and  pelvic  epithelium 
are  sufficient  to  make  the  diagnosis.,  , , 

Prognosis. — In  the  mild  forms,  good  ;  in  the  severe 
forms  with  stone  or  sepsis,  bad. 

Treatment. — Alkaline  mineral  waters  (Celestine,  Vichy) 
may  be  used  to  neutralize  the  urine  if  acid.  Citrate  of  po- 
tassium is  sometimes  given.  If  the  urine  is  alkaline,  benzo- 
ate  of  soda  may  be  used  or  monosodium  phosphate.  Hexa- 
methylenamin  is  of  great  value,  but  only  when  the  urine  is 
acid.  Surgical  treatment  is  indicated  in  the  stone,  pyelo- 
nephrosis,  or  in  very  severe  cases. 

CYSTITIS  AND  CYSTOPYELITIS.1 

Definition. — An  inflammation  of  the  bladder  and  often 
of  the  pelvis  of  the  kidney,  due  to  infection  with  various 
bacteria. 

Etiology. — Usually  the  colon  bacillus  is  the  exciting 
cause,  but  pus  cocci,  gonococci,  typhoid  bacilli,  tubercle 
bacilli,  and  other  bacteria  may  be  the  cause.  Congenital 
malformations  predispose  to  bladder  infections.  The  infec- 
tion usually  takes  place  through  the  urethra,  may  follow  the 
introduction  of  foreign  bodies  into  the  bladder,  and  very 
rarely  tumors  or  bladder-stones  may  be  the  cause.  Some- 
times the  infection  seems  to  come  through  the  circulation, 
and  at  others  it  is  apparently  an  extension  from  an  enteritis 
or  colitis.  Most  cases  occur  in  infants  under  eighteen 
months  of  age. 

Symptoms. — The  disease  is  characterized  by  great  rest- 
lessness, loss  of  appetite,  great  thirst,  high  irregular  fever, 
loss  of  weight,  anemia,  and  frequently  vomiting  and  some 
bowel  disturbance,  which  may  obscure  the  diagnosis.  There 
are  also  mild  forms,  with  only  minor  local  symptoms.  In 
the  severe  forms  there  is  vesical  tenesmus  and  painful  fre- 
quent urination.  There  is  sometimes  pain  on  pressure  over 
the  bladder  and  kidneys.     There  is  usually  a  leukocytosis. 

Urinary    Findings. — The    specific    gravity  is    usually  low 

1  Abt,  Journal  of  the  American  Medical  Association,  December  14,  3907, 
p.  1972. 


THE   URINE  IN  INFANCY  AND   CHILDHOOD.       269 

(1.007-1.015).  The  urine  is  cloudy  and  acid  in  reaction 
when  the  colon  bacillus  or  tubercle  bacillus  is  present,  and 
usually  alkaline  in  infections  with  the  staphylococcus  and 
streptococcus.      Albumin  is  present,  as  a  rule,  and  pus  and 

epithelium  are  found  on  microscopic  examination. 

Diagnosis. — This  is  made  on  the  urinary  findings,  and 
in  all  cases  of  high  irregular  fever  the  urine  should  be  ex- 

ainined.  In  the  tuberculous  cases  there  is  liable  to  be 
marked  pallor,  cachexia  and  malnutrition,  and  blood-clots 
may  l»e  passed.  In  calculus  hypogastric  pain  is  more 
marked,  there  may  be  difficulty  in  urinating,  hematuria  is 
frequent,  and  there  may  be  pain  on  deep  pressure  on  the 
perineum.     Sounding  for  stone  may  settle  the  diagnosis. 

Prognosis. — This  is  variable.  Most  cases  recover  in  a 
week  or  two  if  promptly  treated,  while  others  drag  along  a 
most  chronic  and  di -appointing  course. 

Treatment. — In  a  measure  this  will  depend  on  the 
cause.  Calculi  or  tumors  should  be  removed  if  present. 
Internally,  hexamethylenamin  gives  the  best  results,  and  this 
may  be  given  in  doses  of  1  grain  four  times  a  day  in  an 
infant  one  year  of  age,  and  the  dose  gradually  increased. 
It  acts  only  if  urine  is  acid.  Monosodium  phosphate,  grains 
1  to  5,  may  be  given  in  sweetened  water  to  render  urine  acid. 
Salol  has  also  been  advised,  and  guaiacol  in  drop  doses  in 
orange  juice  may  be  used.  Guaiacol  carbonate  may  be 
given  in  1 -grain  doses.  Potassium  citrate  may  be  used  in 
place  of  the  above.  Irrigation  of  the  bladder  is  not  to  be 
advised  except  in  severe  infections  with  the  staphylococcus 
or  streptococcus. 

RENAL  CALCULI 

Small  calculi  are  frequent  in  early  infancy.  These  are 
chiefly  uric  acid  or  urates,  are  quite  small,  and  are  apparently 
usually  passed  through  the  ureter.  They  may  cause  pyelitis, 
colic,  or  give  rise  to  no  symptoms. 

In  older  children.  There  is  pain  over  the  kidney  region, 
radiating  to  the  opposite  side  and  downward.  Renal  colic 
may   occur   if    the   stone   is   passed   into   the   ureter.       The 


270  DISEASES  OF  INFANTS  AND  CHILDREN. 

Rontgen    rays   are   frequently  used  to  detect    stone  in  the 
kidney. 

Treatment. — Alkaline  treatment  just  sufficient  to  render 
urine  neutral.     If  diagnosis  is  clear,  surgical  treatment. 

PERINEPHRITIS. 

Definition. — Inflammation  about  the  kidney. 

Ktiology. — Trauma.     Frequently  no  cause  can  be  found. 

Pathology. — An  abscess  forms  which  burrows  between 
the  muscle  sheaths  in  one  direction  or  another. 

Symptoms. — The  onset  may  be  sudden,  with  fever,  chill, 
and  localized  tenderness,  or  it  may  be  gradual  with  pain, 
stiffness  of  the  hip  muscles,  and  lameness.  These  symptoms 
increase,  fever  appears,  and  child  becomes  bedridden. 

There  is  scoliosis  with  concavity  toward  the  affected  side, 
the  thigh  is  flexed,  extension  is  painful,  but  all  other  move- 
ments of  the  hip  may  be  made.  The  cases  last  weeks  or 
months,  and  the  abscess  may  rupture. 

Diagnosis. — Often  mistaken  for  hip-joint  disease.  In 
hip-joint  cases  there  is  a  more  gradual  onset,  atrophy,  limita- 
tion of  all  movements,  and  not  of  extension  only.  Psoas 
abscess  from  Pott's  disease  can  be  differentiated  by  locating 
the  diseased  vertebrae. 

Prognosis. — Good  unless  rupture  occurs  into  peritoneal 
cavity. 

Treatment. — Rest  in  bed  with  hot  or  cold  applications. 
If  suppuration  occurs,  surgical  treatment. 


THE  GENITAL   ORGANS.  271 

THE  GENITAL  ORGANS. 

MALFORMATIONS  OF  THE  GENITALIA. 

Hypospadias. — The  urethral  opening  is  on  the  under- 
side of  the  penis,  some  distance  from  the  glans.  In  some 
cases  there  may  be  a  fissure  in  the  perineum,  which  may  lead 
to  the  diagnosis  of  hermaphroditism,  especially  if  the  testes 
are  undescended. 

Epispadias. — The  urethral  opening  is  on  the  dorsal 
surface  of  the  penis. 

Exstrophy  of  the  Bladder. — A  more  or  less  complete 
absence  of  the  abdominal  wall  in  the  median  line  which 
exposes  the  bladder.  This  organ  is  also  fissured,  and  appears 
as  a  red  velvety  surface  on  which  the  openings  of  the  ureters 
may  be  made  out.     The  treatment  is  surgical. 

Cryptorchidism  (Undescended  Testicle). — The  testes 
usually  descend  from  their  fetal  position  below  the  kidney 
into  the  scrotum  during  the  ninth  month  or  shortly  after 
birth.  In  some  cases  they  may  remain  in  the  abdominal 
cavity  or  in  the  inguinal  canal.  If  nearly  in  the  scrotum 
they  may  descend  on  manipulation,  otherwise  they  are  best 
let  alone  unless  they  give  trouble,  when  removal  may  be  ad- 
visable.1 

Adherent  Prepuce. — This  is  found  in  nearly  every 
male  infant.  The  prepuce  should  be  forcibly  retracted,  the 
smegma  washed  off,  and  the  glans  covered  with  a  little  oint- 
ment. This  should  be  done  daily  until  there  are  no  more 
adhesions.  The  adherent  prepuce  may  cause  frequent  and 
painful  urination,  and  the  irritation  may  lead  to  the  habit  of 
masturbation. 

Phimosis. — The  prepuce  has  such  a  narrow  orifice  that 
it  cannot  be  retracted.  The  orifice  may  be  so  small  as  to 
interfere  with  the  free  passage  of  the  urine.  It  may  cause 
balanitis,  painful  urination,  night  terrors,  and  other  reflex 
conditions,  such  as  retention  or  incontinence  of  urine.     The 

1  Bland-Sutton,  "  The  Value  of  the  Undescended  Testicle,"  The  Prac- 
titioner, January,  1910,  p.  19. 


272  DISEASES  OF  INFANTS  AND  CHILDREN. 

prepuce  may  be  stretched  or  cut  so  as  to  allow  retraction. 
Thorough  anointing  with  glycerin  greatly  facilitates  retrac- 
tion.    Circumcision  is  to  be  preferred  in  most  cases. 

DISEASES  OF  THE  MALE  GENITALS. 

Balanitis. — An  inflammation  of  the  prepuce  caused  by 
uncleanliness  or  phimosis.  There  are  edema,  swelling,  and  a 
discharge  of  pus.  Cleanliness,  the  use  of  antiseptic  solutions, 
and  applications  of  lead  water  and  opium  or  of  ice  may  be 
sufficient.  It  may  be  necessary  to  slit  up  the  prepuce  in 
order  to  clean  it  properly. 

Urethritis. — This  may  result  in  young  children  some- 
times from  uncleanliness,  more  often  from  gonorrheal  infec- 
tions, from  direct  contact.  The  disease  resembles  that  of 
adults,  but  constitutional  symptoms  are  not  as  severe  or  may 
even  be  absent.  The  treatment  is  as  in  adults.  Guard 
against  infecting  the  conjunctiva. 

Hydrocele. — This  is  an  effusion  of  fluid  into  the  pouch 
brought  down  with  the  testicle.  In  the  congenital  hydrocele 
there  is  direct  communication  between  the  tunica  vaginalis 
and  the  peritoneal  cavity.  The  fluid  may  disappear  slowly 
into  the  abdomen.  It  may  be  mistaken  for  a  hernia.  In 
the  ordinary  form  the  canal  is  closed  above  and  there  is  a  fluc- 
tuating tumor,  translucent  and  dull  on  percussion.  There 
may  also  be  hydrocele  of  the  cord,  which  is  sometimes 
encysted,  giving  rise  to  a  small  tumor. 

Treatment. — In  the  congenital  form  a  truss  should  be  worn 
until  adhesions  have  shut  it  off  from  the  peritoneal  cavity. 
Absorption  frequently  occurs.  The  scrotum  may  be  painted 
with  collodion.     Iodid  of  potassium  internally. 

DISEASES  OF  FEMALE  GENITALIA. 

Vulvovaginitis. — Definition. — Inflammation  of  the 
vulva,  vagina,  and  frequently  of  the  urethra  as  well.  It 
may  be  simple  or  gonorrheal.1 

1  Holt,  "  Vulvovaginitis,"  New   York  Medical  Journal,  March  18  and  25, 
1905. 


THE  GENITAL   GROANS.  273 

Etiology. — Direct  contact,  either  sexual    or  by  handling; 

infection  less  frequently  takes  place  from  towels,  water- 
closet  seats,  and  the  like.  It  may  be  the  result  of 
injury.  Small  epidemics  may  occur  in  hospitals  and  insti- 
tutions. 

Symptoms. — Redness  and  swelling  of  the  parts,  excoria- 
tions of  the  thighs,  pain  on  micturition.  In  the  simple  form, 
a  whitish,  yellowish,  or  greenish  discharge.  In  the  gonor- 
rheal form  the  discharge  is  yellow  and  abundant.  Crusts  form 
on  the  discharge  drying.  There  may  be  suppuration  of  in- 
guinal  glands.      Iu  gonorrheal  cases  there  may  be  arthritis. 

Diagnosis. — Differentiation  by  microscopic  examination 
of  the  pus. 

Prognosis. — The  simple  form  is  cured  in  two  or  three 
weeks  with  careful  treatment ;  without  treatment  it  lasts  in- 
definitely. The  gonorrheal  forms  last  weeks,  even  months, 
and  relapses  are  frequent. 

Treatment. — Isolate  where  there  are  other  children.  If 
severe,  keep  in  bed.  Flush  vagina  several  times  daily  with 
boric  acid  (saturated  solution):  permanganate  of  potassium 
(1  :  4000)  or  bichloride  of  mercury  (1  :  10,000).  Follow 
this  in  obstinate  cases  with  protargal  solutions  3  per  cent., 
and  in  resistant  cases  10  to  20  per  cent.  Apply  oxid  of  zinc 
ointment  freely  over  vulva  and  thighs.  Place  over  this  a 
sterile  pad.  A  napkin  should  be  used  in  younger  children  and 
closed  drawers  in  older  ones  to  prevent  infection  of  the  eyes. 

Gangrenous  Vulvitis  {Noma). — A  gangrene-like  can- 
crum  oris  beginning  either  alone  or  with  that  disease  (see 
same).  The  general  course  and  treatment  are  the  same  as  in 
that  disease.  If  the  patient  survives  there  may  be  atresia 
of  the  vagina. 

Herpes  of  the  Vulva. — This  may  occur  on  the  skin  or 
mucous  membrane  or  both.  In  its  appearance  and  course  it 
resembles  the  same  condition  seen  in  the  mouth  or  about  the 
lips.  Cleanliness  and  a  dusting  powder  are  all  that  is  re- 
quired. 


274  DISEASES  OF  INFANTS  AND  CHILDREN. 

DISEASES  OF  THE  BLADDER, 

Vesical  Calculi. — These  are  rare  in  infants,  but  may  be 
met  with  in  older  children.    They  are  usually  uric-acid  stones. 

Symptoms. — Pain  on  urination,  sudden  stoppage  of  urine, 
incontinence  of  urine  often  absent  at  night,  and  prolapse  of 
the  rectum. 

Diagnosis. — By  use  of  a  sound. 

Treatment. — Surgical. 

Vesical  Spasm. — Frequent  micturition  with  intense 
pain,  due  usually  to  very  acid  urine. 

Treatment. — Alkaline  waters  in  abundance,  citrate  of 
potassium,  and  hyoscyamus. 

Enuresis l (Incontinence  of  Urine;  Wetting  the  Bed). — 
Definition. — Frequent  involuntary  urination. 

Etiology. — It  may  be  due  to  malformations  of  the  geni- 
talia, to  malformations,  injury  or  disease  of  the  nervous 
system.  The  usual  form  considered  here  is  a  neurosis,  and 
both  genitalia,  and  organically  the  nervous  system,  are  nor- 
mal. The  causes  may  not  be  discoverable ;  it  may  be  due 
to  reflex  action  due  to  very  acid  urine,  worms,  adherent  fore- 
skin, and  general  irritability  of  the  nervous  system.  The 
causes  are  too  numerous  to  mention,  but  among  them  enlarged 
tonsils  and  adenoids  should  not  be  forgotten.  In  many  cases 
where  there  is  infection  of  the  urinary  passages  hexamethyl- 
enamin  may  be  given,  and  salol  is  often  useful. 

Symptoms. — The  incontinence  may  occur  by  day  or  night, 
or  both,  and  varies  greatly  in  severity.  The  urine  is  passed 
in  considerable  quantity  at  a  time  and  does  not  drip  gradu- 
ally.    It  may  occur  only  at  times. 

Prognosis. — The  cases  due  to  organic  nervous  diseases  are 
hopeless.  Those  due  to  malformations  may  be  sometimes 
relieved  by  surgical  measures.  In  the  ordinary  cases  cure 
may  result  at  any  time.     It  may  last  until  five  or  six  years 

1  Williams,  "  Nocturnal  Enuresis  and  Thyroid,"  Lancet,  May,  1,  1909, 
p.  1245.  V.  C.  de  Bainville,  "  Enuresis,  Nocturnal,  Causes  and  Treat- 
ment of,"  Practitioner,  March,  1906,  p.  396.  C.  G.  Kerley,  "Inconti- 
nence of  Urine,"  Boston  Medical  and  Surgical  Journal,  August  16,  1906, 
p.  172. 


THE  GENITAL   ORGANS.  275 

of  age  or  even  to  puberty.  With  persistent  treatment  many 
eases  can  be  relieved. 

Treatment. — Relieve  the  cause  where  possible.  Build  up 
general  health.  If  urine  is  very  acid  give  alkaline  diuretics 
or  citrate  of  potassium.  Avoid  irritating  articles  of  diet, 
especially  tea  and  coffee.  The  child  should  be  taught  to 
urinate  as  infrequently  as  possible,  so  as  to  train  the  bladder 
to  be  distended.  But  little  fluid  should  be  given  after  4  p.  m. 
in  the  nocturnal  cases,  and  the  bladder  should  be  emptied  at 
bedtime.  If  the  urine  is  scanty  see  that  the  child  has  sufficient 
water  at  other  times.  If  the  urine  is  very  abundant  diminish 
amount  of  fluid.  Belladonna  or  atropin  is  the  most  useful 
drug ;  loVo"  gr-  °f  atropin  may  be  given  for  each  year  of  the 
elii Id's  age;  and  it  is  best  given  at  4  and  10  p.  M.  ;  later  at 
4,  7-10  P.  M.  (Holt).  The  quantity  may  be  gradually  in- 
creased until  flushing  of  the  face  occurs,  and  the  dose  should 
then  be  diminished  very  slightly.  This  must  be  kept  up  a 
Ions:  time.  Strvchnin  and  nux  vomica  are  also  valuable, 
especially  in  the  diurnal  cases.  Faradism  or  passage  of  a 
sound  sometimes  gives  relief.  Williams  suggests  the  use 
of  thyroid  extract;  from  J  to  2 J  grains  may  be  given 
three  times  a  day.  The  initial  dose  should  be  small 
and  the  increase  made  gradually.  Care  should  be  taken 
not  to  give  too  much,  and  the  patient  should  be  under 
observation. 

Cystitis. — Definition. — An  inflammation  of  the  bladder. 
This  may  or  may  not  be  associated  with  a  pyelitis. 

Etiology. — The  inflammation  is  due  to  bacteria,  usually  the 
colon  bacillus,  more  rarely  the  typhoid  bacillus,  tubercle  bacil- 
lus, or  pyogenic  micrococci.  Gonorrheal  cystitis  is  rare.  Cys- 
titis is  much  more  common  in  girls  than  in  boys. 

Symptoms. — Infections  of  the  urinary  tract  are  frequently 
overlooked  in  children.  There  are  restlessness,  loss  of  appe- 
tite, an  irregular  but  persistent  fever,  and  pain,  usually  referred 
to  the  abdomen  if  the  child  is  old  enough  to  locate  it.  The 
urine  is  acid  and  contains  pus  and  bacteria.  In  staphylococcic 
and  streptococcic  infections  the  urine  is  alkaline.  There  may 
or  may  not  be  symptoms  distinctly  referable  to  the  genito- 


276  DISEASES  OF  INFANTS  AND  CHILDREN. 

urinary  tract;  if  present  these  are  frequent  and  painful  mic- 
turition and  chafing  of  the  external  genitalia. 

Diagnosis. — This  depends  upon  the  examination  of  the 
urine.  The  urine  may  be  drawn  with  a  catheter  if  neces- 
sary. 

Prognosis. — This  is  usually  good  if  the  child  is  properly 
treated.  Occasionally  the  disease  persists  in  spite  of  treat- 
ment. 

Treatment. — Local  treatment  and  washing  of  the  bladder  is 
liable  to  do  more  harm  than  good  in  young  children.  Hexa- 
methylenamin  (urotropin)  may  be  given  internally  in  doses 
of  from  J  to  1  gr.  three  or  four  times  a  day.  Salol  may 
also  be  used,  and  in  persistent  cases  guaiacol  may  be  admin- 
istered in  orange  juice. 


DISEASES  OF  THE  SKIX. 


277 


DISEASES    OF    THE    SKIN.1 

CONGENITAL   ICHTHYOSIS. 
(  Keratoma  Diffusum  ;    Fish-skin  Disease  ;    Xeroderma. 

Definition. — A    congenital  disease  of  the  -kin   charae- 
terized  by  dryness,  sealiness,  and  a  thiekening  of  the  skin. 


Fig.  07.— Ichthyosis  congenita  :  rase  photographed  when  four  days  old  :  mother 
pregnant  seven  time-,  giving  birth  the  fifth  and  the  last  (present  case*  to  infants 
with  congenital  ichthyosis  (from  Stelwagon,  courtesy  of  Dr.  J.  MacF.  Winfield). 

1  See  Stelwagon,  A  Treatise  on  Diseases  of  the  Skin,  for  further  references. 
T.  C.  F<  ix,  •  Skin  Diseases  of  the  Young  Child,"  Practitioner,  Oct.,  1905,  p.  565. 


278  DISEASES  OF  INFANTS  AND  CHILDREN. 

Etiology. — There  may  be  an  hereditary  tendency  to  the 
disease. 

Pathology. — The  condition  is  usually  regarded  as  an 
inherited  deformity.  There  is  thickening  of  the  epidermis, 
especially  of  the  horny  layer. 

Symptoms. — -This  condition  may  be  present  at  birth  or 
develop  later ;  it  is  usually  not  noted  until  the  end  of  the 
first  or  second  year.  There  are  all  gradations  in  severity, 
from  a  scaly,  parchment-like  thickening  of  the  skin  to  thick 
plate-like  scales. 

Diagnosis. — Usually  easy ;  care  should  be  taken  to  ex- 
clude scaly  eczemas  and  linear  nsevus. 

Prognosis. — Many  of  the  cases  are  born  prematurely 
and  may  die  soon  afterwards.  In  the  cases  noted  later  the 
disease  does  not  affect  life,  but  the  outlook  as  regards  cure  is 
bad. 

Treatment. — Thyroid  tablets  may  be  given  a  trial  in- 
ternally. Externally,  frequent  baths  with  an  ointment  con- 
taining salicylic  acid  may  be  tried. 

ECZEMA. 
(Salt  Rheum;  Tetter.) 

Definition. — An  inflammation  of  the  skin,  which  may 
be  acute,  subacute,  or  chronic.  It  is  characterized  by  various 
lesions,  as  erythema,  papules,  vesicles,  and  pustules,  either 
alone  or  in  combination.  There  is  more  or  less  infiltration 
of  the  skin,  together  with  a  variable  amount  of  exudate,  and 
usually  intense  itching. 

Etiology. — Certain  children  seem  predisposed  to  eczema. 
The  exciting  cause  may  be  any  irritation — heat,  cold,  para- 
sites, rough  clothing,  scratching,  and  the  like.  Intestinal 
disturbances  may  also  cause  it. 

Pathology. — The  changes  in  the  skin  are  those  of  an 
acute  or  chronic  inflammation,  as  the  case  may  be. 

Symptoms. — Only  the  more  important  infantile  forms 
can  be  mentioned.  Eczema  is  a  disease  of  countless  mani- 
festations and  varieties.  The  eczema  of  older  children  resem- 
bles that  of  adults. 

Eczema  Mucosum  or  Intertrigo. — This  develops  where  two 


DISEASES  OF  THE  SKIN.  279 

surfaces  come  together,  as  in  the  inner  side  of  the  thighs  or 

axillas.     It  is  frequently  caused  by  uncleanliness  or  irritating 

stools.      There   is   intense  redness  of  the  skin  and  exudate, 

rendering  the  surface  moist.     There  is  little  itching. 
©  © 

Eczema  Vesiculosum  (Milk  ( Yusf). — A  form  frequently 
seen  on  the  face  of  infants.  There  is  at  first  redness ;  then 
small  vesicles  appear  which  are  likely  to  coalesce ;  and  when 
the  top  is  scratched  off,  a  yellowish-brown  crust  forms. 

Seborrheic  Eczema. — This  is  most  frequently  seen  on  the 
scalp  in  connection  with  seborrhea ;  it  may,  however,  be 
seen  elsewhere  on  the  body.  There  are  greasy,  yellowish 
scaly  crusts  underneath  which  there  is  an  inflammation  of 
the  skin.     There  is  itching. 

Pustular  Eczema  of  the  Scalp. — There  are  numerous  pus- 
tules which  break,  and  the  dried  pus  and  hair  form  a  crust 
over  the  head.  Lice  may  be  the  exciting  cause.  In  some 
cases  no  definite  cause  can  be  assigned. 

Simple  Chronic  Eczema  (Eczema  Rubruni). — The  most  fre- 
quent form  of  eczema.  The  face  is  most  often  affected,  but 
the  body  may  also  be  involved.  There  are  first  red  papules 
which  run  together.  Exudation  follows,  and  this  dries,  form- 
ing crusts.  Bleeding  is  frequent.  The  itching  is  intolerable, 
as  a  rule.  Later,  considerable  thickening  of  the  skin  occurs. 
The  disease  can  usually  be  readily  relieved,  but  frequently 
returns  as  soon  as  treatment  is  discontinued. 

Diagnosis. — L^sually  easy.  Syphilis  and  scabies  should 
be  excluded. 

Prognosis. — In  the  acute  cases  the  outlook  is  good. 
The  chronic  cases  always  last  a  long  time  and  tend  to  relapse. 

Treatment. — Good  hygiene  and  proper  feeding  are  essen- 
tial. Each  case  demands  especial  study.  Intestinal  indi- 
gestion, if  it  exists,  should  be  treated.  Overfeeding  is  the 
most  common  error  ;  excesses  in  carbohydrate  the  second.  In 
infants  the  trouble  is  frequently  too  high  fats  and  sometimes 
too  high  sugar  or  proteins.  Tonics  are  often  necessary.  Iron 
or  arsenic  or  cod-liver  oil  may  be  useful. 

Cleanliness  and  care  in  regard  to  the  skin  are  important. 
The  part  should  be  cleansed  and  the  crusts  removed  with  oil 
and  soap  and  water.     Water  often  irritates,  and  when  it  does 


280  DISEASES  OF  INFANTS  AND   CHILDREN. 

a  bran  or  starch  bath  may  be  substituted  or  only  oil  used. 
In  the  acute  stage  a  zinc  and  calamine  lotion  is  most  satis- 
factory.    If  itching  is  severe  1   per  cent,  carbolic  acid  may 


Fig.  68.— Method  of  treating  eczema  capitis. 

be  added.  Carron  oil  or  a  substitute  made  from  equal  parts 
of  lime  water  and  oil  of  sweet  almonds  is  useful.  Later, 
oxid  of  zinc  ointment  or  Lassar's  paste  may  be  used.  Tar, 
salicylic  acid,  and  resorcin  are  most  frequently  used  to  stimu- 
late the  skin.  Dusting  powders  are  useful  in  intertrigo  and 
the  milder  forms  of  acute  eczema. 


DERMATITIS  VENENATA. 
(Poison  Ivy  or  Oak  Rash.) 

Definition. — A  vesicular  eruption  caused  by  contact 
with  plants  of  the  rhus  species.  It  may  also  be  caused  by 
irritating  drugs. 

etiology. — There  are  too  many  causes  of  this  eruption 
to  enumerate  them  in  this  brief  space.  By  far  the  most  fre- 
quent, however,  is  the  poison  ivy  or  oak.  Some  persons  are 
peculiarly  susceptible. 

Symptoms. — A  few  hours  or  a  day  after  exposure  there 


DISEASES  OF  THE  SKIN. 


281 


is  an  eruption,  usually  on  the  face,  hands,  and  arm.-,  some- 
times on  the  genitalia  or  other  parts  of  the  body.     The  skin 


Fig.  69. — Dermatitis  venenata  from  exposure  to  paison-4vy,  following  shortly 
alter  exposure  ;  vesicular  and  bullous  lesions  :  not  an  uncommon  type ;  hands  and 
forearms  involved  ;  a  days'  duration  (Stelwagon), 

is    reddened    and    covered    with     numerous    small    vesicles. 
There  are  burning  and  itching. 

Diagnosis. — Usually  easy. 

Prognosis. — Recovery  usually  takes  place  in  a  week  or 
ten  days.     Eczema  may  follow. 

Treatment. — The  calamine  aud  zinc  oxid  lotion  is  use- 
ful. The  fluid  extract  of  grindelia  robusta  diluted  with  water 
(1  : 5)  is  frequently  used.  A  lotion  of  sulphate  of  zinc 
(15  gr.  to  1  pint)  is  useful.  Mild  astringent  and  antiseptic 
applications  are  also  of  service.  Zinc  oxid  ointment  may 
be  applied. 

MILIARIA. 

i  Prickly  Heat ;  Strophulus ;  Red  Gum  ;  Lichen  Tropicus ;  Heat-rash,  etc.  I 

Definition. — An  acute  inflammation  of  the  sweat  glands, 
characterized  by  small  papules  and  vesicles  and  accompanied 
by  itching  and  burning. 

Btiology. — Overheating  either  from  hot  weather,  over- 
heated rooms,  or  too  much  clothing.      It  is  seen  also  in  fevers. 


282  DISEASES  OF  INFANTS  AND  CHILDREN. 

Pathology. — More  or  less  obstruction  of  the  sweat 
glands,  due  to  congestion  and  exudation.  There  are  a  num- 
ber of  different  theories  about  this  condition. 

Symptoms. — There  are  several  forms,  usually  seen 
together.  There  may  be  a  preponderance  of  the  vesicles  or 
of  the  papules.  These  are  discrete,  but  often  closely  set. 
They  vary  in  color  from  transparent  vesicles  to  the  intense 
red  papules.  There  are  itching,  burning,  and  a  pricking  sen- 
sation. 

Diagnosis. — When  irritated  or  rubbed,  the  disease  may 
resemble  an  eczema ;  otherwise  the  diagnosis  is  easy. 

Prognosis . — Good. 

Treatment. — Proper  temperature  and  clothing.  Give  a 
purge.  Apply  a  bland  dusting  powder  liberally.  If  the 
itching  is  intense  apply  a  lotion  of  carbolic  acid,  boric  acid, 
alcohol,  and  water.  Resorcin,  1  gr.  to  the  ounce,  or  satu- 
rated boric  acid  solution  is  useful. 

SEBORRHEA  OF  THE  SCALP. 
(Milk  Crust.) 

Definition. — A  functional  disease  of  the  fat-producing 
glands,  characterized  by  an  excessive  secretion  which  forms 
greasy,  yellowish  crusts  over  the  head. 

Etiology. — This  is  very  frequent  in  infants  and  young 
children,  especially  where  the  scalp  is  not  kept  very  clean. 
After  infancy  is  passed  it  is  not  common  until  after  puberty. 

Pathology. — An  overproduction  of  fat  in.  the  sebor- 
rheic glands.  Some  think  it  is  caused  by  a  short  bacillus 
(Sabouraud). 

Symptoms. — The  scalp  is  covered  more  or  less  com- 
pletely'with  a  greasy,  yellowish,  scaly  crust.  This  may,  if 
neglected,  cause  an  eczema  of  the  scalp. 

Diagnosis. — The  greasiness  of  the  scales  separates  it 
from  psoriasis,  eczema,  and  ringworm. 

Prognosis. — Good,  but  with  a  great  tendency  to  recur. 

Treatment. — Oil  the  scalp  well  and  wash  with  soap  and 
water,  preferably  tar  soap.  Resorcin  ointment  (5  to  10  gr. 
to  the  ounce)  or  a  mild  sulphur  ointment  is  usually  quite 


DISEASES  OF  THE  SKIN.  283 

efficient.     The  scalp  must  be  kept  clean  by  frequent  wash- 
ings with  tar  soap. 

FURUNCULOSIS. 
1  Boils.) 

Definition. — A  condition  in  which  numerous  furuncles 
or  boils  are  present. 

Etiology. — Frequent  in  young  infants,  in  marasmus,  and 
in  malnutrition  from  any  cause.  Uncleanliness  may  be 
another  cause. 

Pathology. — The  furuncle  consists  of  an  inflammation 
the  center  of  which  becomes  necrotic  and  forms  a  "  core." 
Pus-forming  bacteria  are  always  present. 

Symptoms. — Furuncles  in  infants  are  most  frequently 
upon  the  scalp,  but  may  be  anywhere  on  the  body.  Septic 
infection  may  result,  and  gangrene  of  the  skin  may  be  a  cause 
of  death. 

Diagnosis. — This  is  easy.     Syphilis  should  be  excluded. 

Prognosis. — In  very  young  and  very  weak  children  this 
may  prove  fatal.      In  stronger  children  the  outlook  is  good. 

Treatment. — Good  hygiene  and  feeding.  Syrup  of  the 
iodid  of  iron,  arsenic,  and  other  tonics  are  advised.  The 
boils  should  be  opened  and  mild  antiseptic  dressings  applied 
and  kept  in  place  with  bandages.  Chronic  furunculosis  may 
be  treated  by  means  of  vaccines.  The  variety  of  organism 
present  should  be  determined.  Vaccines  may  be  made  from 
this  or  the  stock  vaccines  may  be  used  ;  50,000,000  or  some- 
what less  may  be  given  as  an  initial  dose  and  repeated  in  a 
week.  The  dose  may  be  gradually  increased,  but  should 
neither  be  so  large  nor  so  frequently  repeated  as  to  cause  any 
symptoms.  The  initial  dose  for  streptococcus  vaccine  is  about 
one-fourth  the  above. 

IMPETIGO  CONTAGIOSA. 

Definition. — A  contagious  disease  seen  especially  in  in- 
fants and  young  children  and  characterized  by  vesicopustules, 
especially  on  the  exposed  parts  of  the  body. 

Etiology. — Seen  in  young  children,  in  institutions,  and 


284 


DISEASES  OF  INFANTS  AND   CHILDREN. 


among  the  poor.  It  is  readily  communicated  from  one  child 
to  another,  and  it  may  be  inoculated  from  one  part  of  the 
body  to  another. 

Pathology. — The    specific    cause    is    some    pus-forming 
germ;  staphylococci  and  streptococci  have  both  been  isolated. 


Fig.  70.— Impetigo  contagiosa  (after  Lesser). 

There  is  a  bleb-like  vesicle,  the  contents  of  which  become 
turbid  and  then  dry. 

Symptoms. — The  lesions  are  found  chiefly  on  the  face 
and  hands  and  the  parts  of  the  body  which  the  child  can 
scratch.  The  pustule  is  on  a  slightly  reddened  base.  The 
resulting  crust  looks  as  if  it  were  "stuck  on."  When  this 
scab  falls  off  it  leaves  a  reddened  area  which  gradually 
clears  up. 

Diagnosis. — Easy.  It  has  been  confused  with  pem- 
phigus, chicken-pox,  and  small-pox. 


DISEASES   OF  THE  SKIN.  28o 

Prognosis. — Good.  It  lasts  several  weeks,  and  by  auto- 
inoculation  may  be  kept  up  much  longer. 

Treatment. — Some  antiseptic  wash  or  ointment  should 

be  applied  and  auto-inoculation  prevented  if  possible.  A 
diluted  ointment  of  ammoniated  mercury  is  a  very  satisfac- 
tory application. 

ECTHYMA. 

Definition. — A  disease  seen  in  poorly  nourished  chil- 
dren, characterized  by  discrete,  flat  pustules  on  an  inflamed 
base. 

Etiology. — In  very  poor  children,  in  malnutrition  from 
disease,  and  from  irritation,  such  as  from  bedbugs. 

Pathology. — Streptococci  are  usually  found  in  the  pus- 
tules. They  are  considered  by  some  to  be  the  same  as 
impetigo. 

Symptoms. — The  eruption  is  seen  on  the  legs,  back,  and 
forearms.  The  pustule  appears  about  the  size  of  a  pea, 
becomes  flattened,  and  gets  a  little  larger.  The  base  i- 
indurated,  reddened.  Hemorrhages  frequently  take  place 
into  the  lesion,  causing  them  to  turn  black.  They  last  a 
week  or  two  and  disappear,  new  ones  forming  from  time  to 
time.      There  may  be  pain  and  itching. 

Diagnosis. — From  impetigo  by  the  flat  pustule  on  an 
indurated,  very  much  reddened  base,  and  the  absence  of  any 
tendency  to  coalesce.     Syphilis  should  be  excluded. 

Prognosis. — Good. 

Treatment. — Good  food,  fresh  air,  and  tonics.  Locally, 
antiseptic  dressings.  Ammoniated  mercury  ointment  is  a 
satisfactory  application.  Bacteriologic  vaccines  may  be  tried 
in  resistant  cases. 

URTICARIA. 

(Hives.) 

Definition. — A  condition  characterized  by  the  appear- 
ance of  numerous  wheals  and  by  intense  itching.  In  chil- 
dren irregular  forms  are  frequently  seen  in  which  vesicles 
and  papules  are  present. 


286  DISEASES  OF  INFANTS  AND   CHILDREN. 

Etiology. — Certain  children  are  particularly  liable  to 
urticaria.  Indigestion  and  certain  articles  of  diet  are  the 
most  frequent  causes.     At  times  no  cause  can  be  assigned. 

Symptoms. — There  are  papules  and  wheals  over  the 
hands,  feet,  and  body.  The  itching  is  intense.  Scratching 
may  result  in  infecting  the  skin.  After  a  few  hours  or  much 
longer  the  lesions  disappear. 

Diagnosis.— This  is  easy.  Scabies  and  chicken-pox 
should  not  be  mistaken  for  it. 

(See  Henoch's  Purpura,  p.  245.) 

Prognosis. — As  a  rule  good.  In  some  cases  it  recurs 
with  great  persistence. 

Treatment. — Give  a  purge  and  repeat  if  necessary. 
Calomel,  salines,  as  phosphate  of  soda  and  castor  oil,  are  best. 
Give  a  simple,  easily  digested  diet  or  a  milk  diet.  Treat  any 
attendant  indigestion. 

Locally,  applications  of  hot  bicarbonate  of  soda  solutions 
or  hot  soda  baths  may  be  given ;  lotions  of  menthol  (2  gr. 
to  1  oz.)  or  carbolic  acid  (1  per  cent.)  and  water  may  be 
applied. 

Internally,  alkaline  drugs  should  be  tried,  especially  if  the 
tongue  is  clean.  Aromatic  spirits  of  ammonia  is  one  of  the 
best  drugs  to  use.  Ammonium  chlorid  is  useful  and  full 
doses  of  anti pyrin  sometimes  give  relief.  If  sleep  is  much 
disturbed,  bromids  and  chloral,  veronal,  or  similar  drugs  may 
be  given.  A  change  of  air  and  an  out-of-door  life  are  fre- 
quently advisable. 

ALOPECIA  AREATA. 

Definition. — A  disease  characterized  by  patches  of  bald- 
ness without  any  apparent  changes  in  the  skin. 

Etiology. — It  is  slightly  more  frequent  in  boys,  and 
rare  before  five  years  of  age.  The  exciting  cause  is  unknown. 
By  some  it  is  thought  to  be  neurotic,  by  others  parasitic. 

Pathology. — There  are  degenerative  changes  in  the  hair 
bulb  and  in  the  hair  above  it. 

Symptoms. — The  loss  of  hair  over  the  bald  patch  is 
complete.     The  hairs  about  the  edges  of  the  patch  are  often 


DISEASES  OF  THE  SKIN. 


287 


loose,  especially  when  the  patch  is  increasing  in  size.  There 
are  usually  several  patches.     The  entire  scalp  may  be  affected. 

Diagnosis. — Ringworm. — This  rarely  presents  absolutely 
bald  patches ;  the  hairs  are  broken  off  close  to  the  head. 
The  fungus  may  be  demonstrated  in  doubtful  cases. 

Favus. — There  is  rarely  complete  baldness  ;  there  are  crusts 
and  some  inflammatory  reaction. 

Bald  spots  from  abscesses  and  boils  should  be  excluded. 

Prognosis. — Usually  good  in  children.     Sometimes  the 


Fig.  71.— Alopecia  areata  (Hardaway). 


baldness  is  permanent.  It  lasts  months  or  even  years.  A 
downy  growth  on  the  spot  is  favorable.  Relapses  may  occur. 
Treatment. — Internally,  touics  as  indicated.  Iron,  cod- 
liver  oil,  arsenic,  and  strychnia  are  the  most  useful.  Locally, 
washing  with  green  soap  or  naphthol  sulphur  soap,  and 
applying  stimulating  ointment  or  lotions.  Beta-naphthol  tar, 
sulphur,  and  cantharides  are  the  most  frequently  used. 


288 


DISEASES  OF  INFANTS  AND  CHILDREN. 


PEDICULOSIS. 

(Phthiriasis;  Lousiness*) 

Definition. — This  term  is  applied  to  the  irritation  of  the 
skin  and  scalp  caused  by  lice.  There  are  three  species  : 
pediculus  capitis,  or  head  louse  ;  pediculus  corporis,  or  clothes 
or  body  louse  ;  and  pediculus  pubis,  or  crab  louse.  The  last- 
named  is  not  often  seen  in  young  children. 

Etiolgy. — Lice  are  usually  seen  in  the  poorer  classes  of 
people.     They  are  communicated  by 
direct  infection. 

Pathology. — The  irritation  pro- 
duces inflammation  of  the  skin  and 
enlargement  of  the  neighboring  lymph 
nodes. 

Symptoms. — Head  Lice. — These 
are  rarely  seen  anywhere  except  on  the 
head.  The  lice  themselves  are  seen 
on  the  hairs,  and  there  are  always 


Pig.  72.— Male  pediculus  capitis 
(after  Kiichenmeister). 


Fig.  73.— Nits  of  pediculus  capitis 
(after  Kaposi). 


numerous  little  hard  pinpoint-sized  bodies,  called  nits,  at- 
tached to  the  hairs.  There  are  itching  and  inflammation  of 
the  scalp  and  nape  of  the  neck,  together  with  enlargement  of 
the  post-cervical  lymph  nodes. 

Body  Lice. — These  are  seen  on  the  body  and  in  the  folds 
of  the  clothing.  They  may  be  suspected  from  the  many 
scratch-marks  on  the  body.     There  may  be  pigmentation. 


DISEASES   OF  THE  SKIN.  289 

Crab  Lice. — In  older  children  they  may  be  found  about 
the  genitalia,  as  in  adults.  In  young  children,  if  seen  at  all, 
they  are  usually  on  the  eyebrows  or  eyelashes. 

Diagnosis. — This  is  made  by  finding  the  lice. 

Prognosis. — It  requires  considerable  time  to  rid  the 
body  of  lice  if  once  infected. 

Treatment. — Head  Lice. — Anoint  the  hair  with  crude 
petroleum.  (Caution,  very  inflammable.)  Put  on  a  cap  and 
allow  to  remain  on  twelve  hours.  Wash  the  head  in  soap 
and  water.  The  nits  may  be  removed  by  using  hot  vinegar 
and  a  fine-tooth  comb.  Tincture  of  cocculus  indicus,  diluted 
several  times  with  water,  is  also  used.  Sulphur-naphthol 
soap  may  be  used  in  mild  cases.  The  accompanying  eczema 
should  be  treated  as  such. 

Body  Lice. — Sulphur-naphthol  soap  and  a  full  bath  should 
be  used.  The  clothing  should  be  disinfected  by  boiling  or 
ironing. 

SCABIES. 

(Itch.) 

Definition. — A  contagious  disease  caused  by  the  acarns 
scabies,  and  characterized  by  intense  itching  and  an  eruption 
of  papules,  vesicles,  and  pustules. 

Ktiology. — It  is  seen  mostly  in  the  poorer  classes.  In- 
fection occurs  from  direct  contact,  unclean  bedding,  clothing, 
and  the  like. 

Pathology. — The  lesions  are  caused  by  the  irritation  of 
the  parasite  burrowing  in  the  skin.  Vesicles  and  papules 
are  always  present,  and  frequently  pustules,  these  last  prob- 
ablv  from  infection  with  pus  germs.  The  female  parasite 
alone  burrows  into  the  skin.  The  burrows  can  often  be  seen 
as  fine  dark  lines  from  J  to  1J  in.  in  length. 

Symptoms. — These  are  the  intense  itching,  which  is 
worse  at  night,  and  the  characteristic  eruption  seen,  especially 
on  the  hand,  between  the  fingers,  about  the  wrists,  folds  of 
the  elbow,  axillas,  groins,  genitalia,  inner  side  of  the  thighs, 
and  the  back  of  the  knees.  The  scalp  and  face  are  never 
involved.     There  may  be  eczema  as  a  complication. 

19 


290  DISEASES  OF  INFANTS  AND  CHILDREN. 

Diagnosis. — The  intense  itching,  especially  at  night, 
and  the  character  and  location  of  the  eruption,  make  the 
diagnosis  easy,  as  a  rule.  The  parasite  may  often  be  demon- 
strated. 

Prognosis. — Good. 

Treatment. — Full  baths  with  green  soap,  followed  by 
inunction  with  sulphur  ointment  diluted  to  half  strength,  or 
the  following : 

B     /?-naphthol 4(3j); 

Prepared  chalk 8(,^ij); 

Green  soap 50  (^iss) ; 

Benzoinated  lard 100  (^iij).— M. 

This  should  be  repeated  for  three  days  and  then  under- 
clothing and  bedding  changed  and  sterilized.  If  not  per- 
fectly cured,  repeat.  Soothing  ointments  may  be  applied  if 
eczema  exists. 

RINGWORM.1 

(Tinea  Tricophytina ;  Tr icophytosis ;  Dermatomycosis  Tricophytina.) 

Definition. — A  parasitic  skin  disease  caused  by  fungi  of 
various  kinds,  chiefly,  however,  by  different  species  of  the 
genus  tricophyton.     It  may  affect  the  scalp  or  body. 

Etiology. — The  chief  fungi  are  the  tricophyton  megalo- 
sporon. 

The  disease  is  contagious,  and  is  transmitted  by  direct 
contact,  brushes  and  combs,  wearing  apparel,  and  the  like. 
Ringworm  is  most  common  in  the  young,  and  ringworm  of 
the  scalp  is  almost  entirely  limited  to  children. 

Pathology. — The  fungus  is  easily  demonstrated  in 
scrapings  from  the  edge  of  the  patch  which  have  been  moist- 
ened with  liquor  potassse.  The  fungus  grows  in  the  horny 
layer  of  the  epidermis. 

Symptoms. — Ringworn  of  the  Body  (Tinea  Circinata). — 
This  usually  begins  with  one  or  more  slightly  scaly,  reddened 
spots,  which  are  sharply  outlined  and  raised  a  little  above 
the  surface.  These  grow  and  the  center  clears  up  partially, 
so  that  the  spots  are  ring-shaped  areas  with  a  raised,  reddened 

1  T.  C.  Fox,  "  Ringworm  of  the  Scalp,  Treatment  of,"  Practitioner, 
April,  1905,  p.  468. 


DISEASES  OF  THE  SKIN.  291 

border  and  a  slightly  scaly  center.    The  appearance  is  usually 
characteristic. 

Ringworm  of  the  Scalp  (Tinea  Tonsurans). — One  or  more 
scaly  bald  spots  are  seen.  The  edges  are  sometimes  slightly 
hyperemic  and  raised.  The  hairs  are  broken  off  short  near 
the  scalp  and  can  be  seen  on  close  inspection. 

Diagnosis. — Usually  easy.  In  the  scalp  the  scaliness 
and  the  short  broken  hairs  separate  it  from  alopecia  and  favus. 
In  seborrhea  the  scales  are  greasy  and  the  affection  general, 
while  in  eczema  there  is  often  an  exudation  and  always 
itching. 

Prognosis. — Eventually  good.  Body  ringworm  is 
usually  cured.  Ringworm  of  the  scalp  is  difficult,  and  re- 
infection is  frequent. 

Treatment. — Separate  towels,  etc.,  for  the  infected  child. 
A  cap  for  the  scalp.  Scrub  with  green  soap  and  hot  water 
and  apply  a  parasiticide.  Beta-naphthol,  sulphur,  resorcin, 
and  the  tincture  of  iodin  are  most  frequently  used.  The  Ront- 
gen  rays  may  be  used  with  good  effect  in  resistant  cases. 

FAVUS. 

(Tinea  Favosa;  Porrigo  Favosa,  etc.) 

Definition. — A  contagious  disease  usually  of  the  scalp 
caused  by  the  Achorion  Schoenleinii  and  characterized  by 
cup-shaped  crusts  which  tend  to  coalesce. 

Ktiology. — It  is  seen  in  poor  children  in  America,  espe- 
cially in  immigrants. 

Pathology. — The  Achorion  Schoenleinii  is  a  vegetable 
parasite,  consisting  of  mycelium  and  spores.  Infection  occurs 
about  a  hair,  the  hairs  fall  out,  and  a  pustule  is  produced. 

Symptoms. — There  are  yellowish  cup-shaped  crusts, 
often  running  together.  The  hairs  are  either  gone  or  are 
split  or  broken.  There  are  atrophy  and  scarring  of  the  skin. 
There  is  a  peculiar  characteristic  mouse-like  odor. 

Diagnosis. — The  characteristic  crusts  and  odor,  with 
atrophy  of  the  skin  and  brittle  hairs,  usually  make  the  diag- 
nosis easy, 


292 


DISEASES  OF  INFANTS  AND   CHILDREN. 


Prognosis. — Good,  if  treated  early.  Permanent  bald- 
ness may  result. 

Treatment. — Oil  the  scalp  and  wash  with  soap  and 
water,  removing  all  crusts.  Cut  the  healthy  hair  short. 
Pull  out  the  hairs  of  the  affected  areas.  Apply  parasiticides. 
Resorcin  and  lanolin  (1  :  8),  or  sulphur,  tar,  and  mercury. 
The  Rontgen  rays  may  be  used  with  good  effect. 


GANGRENE. 

Gangrene  occasionally  is  seen  in  infants  and  young  children, 
and  is  always  a  very  serious  condition.  It  may  be  due  to  a 
great  variety  of  causes.  The  commonest  form  is  noma,  which 
has  been  described  under  that  heading,  but  which  also  may 


Fig.  74. — Gangrene  of  the  great  toe. 

affect  the  genitalia  and  sometimes  other  parts  of  the  body. 
Gangrene  of  the  skin  may  occasionally  be  met  with  in  other 
infectious  diseases,  particularly  chicken-pox,  and  it  may  also 
be  seen  to  follow  septic  infections  of  the  skin  and  pemphigus. 
Raynaud's  disease  is  sometimes  met  with  in  early  life,  and 
occasionally  gangrene  may  follow  embolus  or  thrombosis. 


DISEASES  OF  THE  SKIN.  293 

DRUG  ERUPTIONS. 

Erythematous  eruptions  may  be  produced  by  : 

Antipvrin,  resembling  measles  and  diffuse  erythema. 

Arsenic,  occasionally. 

Belladonna,  scarlatiniform  erythema. 

Borax  and  boric  acid. 

Chloral,  scarlatiniform  rash  with  desquamation. 

Copaiba  and  eubebs,  eruption  like  measles. 

Digitalis  (rarely),  scarlatiniform  and  measly  eruption. 

Iodoform,  scarlatiniform. 

Mercury  (rarely),  scarlatiniform  erythema. 

Opium  and  morphia,  rash  resembling  measles  or  scarlatina. 

Quinin,  scarlatiniform  erythema  with  desquamation,  some- 
times attended  with  pyrexia. 

Salicylates  and  salicylic  acid,  scarlatiniform. 

Sulphonal,  macular  and  diffuse  erythema. 

Tar,   erythema    with    fever,  sometimes    an    eruption  like 
measles. 
Urticarial  eruptions  : 

Copaiba  and  eubebs. 

Quinin. 

Salicylic  acid  and  salicylates. 

Santonin. 

Tar  and  creosote. 

Turpentine. 

Valerian. 

Erythema    with    infiltration   and   edema    resembling    ery- 
sipelas.    Aconite,  bromid,  and  iodid  of  potassium. 
Vesicular  aud  bullous  eruption-  : 

Arsenic    (rare),    boric    acid    (rare),  bromids,  iodids,  and 
iodoform. 

Cubebs  and  copaiba  (rare),  quinin. 
Herpes  zoster  : 

Arsenic. 
Pustular  eruption  : 

Antimony. 
Arsenic. 

Bromids. 


294  DISEASES  OF  INFANTS  AND  CHILDREN. 

Iodids. 

Calcium  sulphide. 

Salicylic  acid  (rare). 
Petechial  eruption,  purpura : 

Chloral. 

Copaiba. 

Iodids. 
Cyanosis  : 

Acetanilid. 
Pigmentation : 

Arsenic  (brown). 

Silver  (slate  color). 
Hyperkeratosis,  epidermic  thickening  : 

Arsenic  (epithelioma  has  been  known  to  arise  in  an  area 
of  arsenical  hyperatosis). 

Borax,  eruption  like  psoriasis. 

ACUTE  OTITIS. 

Definition. — An  acute  inflammation  of  the  middle  ear. 

Etiology. — Usually  secondary  to  other  diseases.  The 
majority  of  the  cases  occur  in  winter.  The  most  common 
causes  in  the  order  of  their  frequency  are  simple  catarrhal 
pharyngitis,  measles,  influenza,  dentition,  scarlet  fever,  and 
whooping-cough.  Other  diseases  are  occasional  causes.  In- 
fection takes  place  through  the  Eustachian  tube. 

Pathology. — There  is  a  congestion  of  the  middle  ear  and 
tympanum.  Later,  there  is  either  a  catarrhal  or  purulent 
exudate.     There  may  or  may  not  be  rupture  of  the  ear-drum. 

Symptoms. — In  infants  fever  may  be  the  only  symptom, 
and  the  ear  may  not  be  thought  of  until  the  drum  ruptures 
and  there  is  a  discharge  of  pus,  usually  with  a  fall  of  the 
temperature.  If  the  perforation  is  near  the  center  of  the 
drum,  it  suggests  infection  through  the  Eustachian  tube ;  if 
on  the  periphery,  from  disease  of  the  bones.  There  may  be 
evidence  of  pain  and  discomfort  and  the  child  may  sleep 
poorly.  Sometimes  there  may  be  rolling  of  the  head  and 
evidence  of  pain  on  pulling  the  lobe  of  the  ear.     In  older 


ACUTE  OTITIS.  295 

children  there  is  deafness,  pain,  and  great  restlessness,  and 
sometimes  delirium  or  convulsions. 

Complications. — Mastoiditis,  thrombosis  of  the  lateral 
sinus,  meningitis,  facial  paralysis,  and  involvement  of  the 
internal  ear. 

Diagnosis. — Usually  by  examination  of  the  drum  mem- 
brane, the  deafness,  and  earache.  The  disease  is  frequently 
overlooked  in  infants.  The  ear  should  always  be  examined, 
as  in  unexplained  prolonged  fever  otitis  is  a  frequent  cause. 
If  the  disease  continues  for  a  month,  mastoiditis  should  be 
suspected,  and  if  the  pus  returns  immediately  after  being 
wiped  out  of  the  ear,  the  diagnosis  of  mastoiditis  is  almost 
certain.  Pain,  fever,  redness,  jand  swelling  over  the  ear  are 
later  symptoms. 

Prognosis. — Catarrhal  form  good.  In  the  purulent  form 
some  impairment  of  hearing  often  results. 

Treatment. — Dry  heat  applied  externally.  Salines  and 
leeches  if  seen  early.  A  4  per  cent,  cocaine  solution  may  be 
dropped  in  the  ear  for  pain  or,  better  still,  a  5  to  10  per  cent, 
solution  of  carbolic  acid  in  glycerin. 

If  the  symptoms  persist  or  rupture  of  the  drum  is  threat- 
ened, paracentesis  should  be  done.  After  that,  or  if  rupture 
occurs,  syringing  with  warm  saturated  solutions  of  boric 
acid.  If  there  is  odor  permanganate  of  potassium  solution 
(1  :  4000)  or  peroxid  of  hydrogen  (1  : 4)  may  be  used.  If 
long  in  healing  use  once  daily  a  few  drops  of  1  :  3000  bichlo- 
rid  of  mercury  in  60  per  cent,  alcohol.  Mastoiditis  requires 
prompt  surgical  treatment. 


296  DISEASES  OF  INFANTS  AND   CHILDREN. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  nervous  system  is  only  partially  developed  at  birth, 
and  during  the  first  few  years  its  functions  are  easily  dis- 
turbed, even  by  minor  causes.  The  brain  and  cord  are  rela- 
tively larger  and  softer  than  in  adults.  Reflexes  are  more 
marked  and  brain  inhibition  absent,  or  only  present  to  a  slight 
degree. 

THE    EXAMINATION    OF    THE    NERVOUS    SYSTEM    AND 
THE  SIGNIFICANCE  OF  SYMPTOMS. 

The  history  of  the  illness,  and  especially  of  diseases 
which  may  affect  the  nervous  system,  should  be  gone  into 
carefully.  The  presence  or  absence  of  the  nervous  symp- 
toms noted  below  should  be  determined  by  direct  question- 
ing of  the  mother  or  nurse,  and  a  complete  physical  exam- 
ination of  the  child  should  be  made,  with  especial  reference 
to  the  reflexes,  the  amount  of  power,  the  condition  of  the 
muscles,  and  other  things  having  a  bearing  on  the  nervous 
system,  as  noted  below.  An  exact  knowledge  of  the  normal 
child  is  indispensable  and  can  only  be  acquired  by  experience. 

In  making  a  diagnosis  always  have  the  child  undressed, 
always  try  to  ascertain  the  family  history,  especially  as  re- 
gards syphilis,  alcoholism,  nervous  and  mental  diseases.  Re- 
member that  development  depends  much  upon  environment, 
and  too  much  is  not  to  be  expected  from  neglected  children. 
It  is  well  to  remember  that  there  are  more  functional  than 
organic  diseases  of  the  nervous  system  in  early  life,  and  that 
it  takes  but  little  to  upset  the  nervous  equilibrium  of  the 
young  child. 

Irritability  and  change  in  disposition  are  seen  in 
the  onset  of  most  acute  diseases,  in  chronic  bowel  and  kidney 
disease,  and  the  auto-intoxications. 

Delirium  is  not  uncommon  in  children,  and  is  most  often 
due  to  fever  and,  it  should  be  remembered,  often  with  rather 
low  temperatures.  It  is  also  frequent  as  a  result  of  auto- 
intoxication, as  in  gastro-intestinal  disorders  and  as  the  result 


DISEASES   OF  THE  NERVOUS  SYSTEM.  297 

of  intracranial  disease.     Belladonna,  alcohol,  and  other  drugs 
may  also  be  the  cause. 

Drowsiness  is  frequently  seen,  and  may  be  due  to  a 
variety  of  causes,  among  which  may  be  mentioned  the  ad- 
ministration of  alcohol,  opium,  bromids,  soothing  syrups, 
and  other  drugs  ;  the  poisoning  which  occurs  in  diseases  of 
the  kidney,  liver,  and  also  of  the  stomach  and  intestines  ;  the 
onset  of  measles  and  during  the  course  of  many  febrile  dis- 
orders, such  as  typhoid  fever  and  pneumonia,  after  epileptic 
seizures,  and  of  very  great  importance  during  the  onset  and 
during  the  course  of  brain  diseases,  and  especially  of  menin- 
gitis. 

Coma  is  often  seen  in  meningitis,  diseases  of  the  brain, 
and  later  in  any  severe  affection,  as  in  uremia,  diarrhea,  and 
pneumonia.  It  is  always  a  serious  symptom  and  usually 
means  an  unfavorable  prognosis.  Coma  is  easily  produced 
in  children  by  sleep-producing  drugs. 

Di^iness  or  vertigo  may  be  noted,  the  child  com- 
plains of  things  turning  round  or  that  he  is  falling  when 
there  is  no  danger  of  it,  as  when  in  bed,  and  there  may  be 
disturbance  of  gait  and  station.  This  may  be  due  to  brain 
tumor  (especially  cerebellar),  to  disease  of  the  ears,  to  men- 
ingitis, to  digestive  disturbances,  and  is  occasionally  noted  in 
the  onset  of  acute  diseases. 

Photophobia  is  sometimes  seen  in  meningitis,  especially 
early  in  the  disease,  in  cerebral  hyperemia,  and  to  a  lesser 
degree  in  measles  and  sometimes  in  influenza.  It  may  be 
caused  by  local  disease  of  the  eye,  and  at  other  times  is 
apparently  due  to  irritation  of  the  mouth. 

The  superficial  skin  reflexes  are  not  observed  under 
the  third  day,  and  they  develop  slowly  and  are  comparatively 
constant  at  five  months  of  age,  although  they  are  sometimes 
feeble  or  even  absent  during  the  first  year  or  two  of  life,  and 
in  young  infants  the  area  over  which  a  reflex  may  be  elicited 
is  often  enlarged.  Sometimes  they  appear  at  once  and  at 
other  times  successively.  In  the  latter  case  the  upper  re- 
flexes are  observed  before  the  lower. 

The  knee  jerk  is  present  from  the  second  day  and  in  in- 


298 


DISEASES  OE  INFANTS  AND   CHILDREN 


fants  is  rather  more  marked  than  in  later  life,  and  there  may 
be  what  is  considered  a  marked  increase  without  any  or- 
ganic disease  ;  but  the  deep  reflexes  may  be  difficult  to  elicit 
in  children,  owing  to  only  partial  relaxation  of  the  mus- 
cles. It  is  increased  in  most  cases  of  infantile  cerebral 
paralysis  and  is  usually  absent  in  cases  of  poliomyelitis 
aifecting  the  extensors  of  the  thigh,  in  neuritis,  progressive 
muscular  atrophy,  and  pseudohypertrophic  paralysis. 

Plantar  Reflex.— In  the  adult,  stroking  the  sole  of  the 
foot  causes  quick  flexion  of  the  toes,  inversion  of  the  foot, 
and  often  a  drawing  up  of  the  leg.     In  the  young  infant  the 


Fig.  75.— Normal  plantar  reflex. 

reflex  is  usually  extension  and  a  spreading  out  of  the  toes, 
and  more  or  less  irregular  movements  of  the  leg  and  hip. 
By  the  end  of  the  first  year  50  per  cent,  of  the  reflex  is 
flexion,  and  by  the  third  year  flexion  is  the  normal  reflex. 
Flexion  in  children  who  walk  late  is  a  good  sign. 

Kernig's  Sign. — This  consists  in  the  inability  to  extend 
the  leg  fully  on  the  thigh  when  the  thigh  is  at  a  right  angle 
with  the  trunk,  or  to  flex  the  thigh  at  a  right  angle  with  the 


DISEASES   OF  THE  NERVOUS  SYSTEM. 


299 


trunk  when  the  leg  is  extended  on  the  thigh.  In  other 
words,  when  an  attempt  is  made  to  extend  the  leg  the  con- 
traction of  the  muscles  keeps  the  thigh  at  right  angles  to  the 
body  and  the  legs  at  right  angles  to  the  thigh.  This  is  seen 
chiefly  in  cerebrospinal  fever,  but  it  may  be  noted  both  in 
tuberculous  meningitis  and  in  other  forms  where  the  spinal 
meninges  are  involved.  It  may  be  absent  in  some  cases,  but 
is  sometimes  present  only  intermittently.  It  is  more  often 
present  when  the  knee  jerk  is  increased  than  when  it  is 
diminished.     It  is  rarely  seen  in  other  diseases  of  infancy 


Fig.  76.— Plantar  reflex,  showing  Babinski's  sign. 


except  in  chronic  marasmus,  where  there  is  considerable  mus- 
cular rigidity. 

Chvostek's  Sign. — This  is  the  mechanical  irritability 
of  the  motor  nerves  and  is  best  observed  in  the  facial  nerve, 
although  tapping  over  the  motor  points  elsewhere  will  cause 
contraction  of  the  corresponding  muscles.  A  tap  on  the 
cheek  below  the  malar  bone  causes  a  sharp  contraction  of  the 
muscles  supplied  by  the  facial  nerve.  The  phenomenon  is 
pathologic,  is  rarely  seen  during  the  first  six  months,  but 
after  that  it  indicates  an  abnormal  excitability  of  the  nervous 
system.     It  is  seen  in  tetany,  laryngismus  stridulus,  also  less 


300  DISEASES  OE  INFANTS  AND   CHILDREN. 

often  in  rickets,  and  in  older  children  in  digestive  disturb- 
ances. 

I/ip  Reflex  of  the  Newborn. — This  is  elicited  by  a 
number  of  taps  on  the  upper  lip  a  little  above  the  angle  of 
the  mouth,  or  on  the  lower  lip  a  little  below  it.  In  some 
infants  touching  or  tapping  anywhere  on  the  cheek  will  cause 
it.  The  reaction  consists  in  drawing  the  lip  to  one  side  or  the 
other,  followed  by  a  pouting  or  pursing  up  of  the  lips,  as  if 
the  child  attempted  to  suck  something,  and  lastly,  a  marked 
protrusion  of  the  lips.  It  is  most  easily  elicited  during 
sleep,  becomes  less  marked  as  the  child  grows  older,  and  is 
rarely  noted  after  the  fourth  year.  In  some  cases  of  spastic 
diplegia  there  is  a  similar  reflex  which  may  be  obtained  that 
is  combined  with  chewing  movements. 

Tremor. — This  is  very  rare  in  children.  It  is  seen  in 
multiple  sclerosis,  occasionally  in  a  course  of  infectious  dis- 
eases, and  sometimes  in  brain  tumor. 

Ataxia  is  often  overlooked,  owing  to  the  fact  that  co- 
ordination is  not  very  perfect  in  early  life.  It  is  seen  in 
tumors  of  the  brain,  especially  cerebellar  tumors  and  Fried- 
reich's disease,  also  in  the  severe  choreas.  In  the  transient 
form  it  is  sometimes  seen  after  prolonged  rest  in  bed. 

Tache  Cerebrale. — A  very  light  stroke  on  the  skin 
produces  a  persistent  hyperemia  seen  in  meningitis,  typhoid, 
and  other  fevers.  It  is  seen  also  in  children  with  urti- 
caria. 

Electrical  Reactions. — These  are  almost  impossible 
to  elicit  satisfactorily  in  young  children  and  perhaps  are  best 
left  to  the  expert. 

Pseudoparalysis. — This  is  loss  of  muscular  power  due 
to  other  than  nerve  lesions.  It  presents  the  appearance  of  a 
true  paralysis,  but  that  differential  diagnosis  may  usually  be 
made  by  careful  examination  ;  slight  movements  sometimes 
being  made  on  pinching  or  otherwise  irritating  the  skin. 
Pseudoparalysis  is  seen  in  rickets,  scurvy,  syphilis,  as  well  as 
in  joint  and  bone  disease.  In  some  instances  the  lack  of 
power  is  due  to  weakness ;  in  others,  to  the  child's  inhibiting 
movement  owing  to  pain. 


DISEASES   OF   THE  NERVOUS  SYSTEM.  301 

CONVULSIONS.1 
Definition. — A  convulsion  is  a  motor  discharge  resulting 

in  muscular  contractions  of  one  or   more  parts  of  the  body 

(Sachs). 

Etiology. — During  the  first  few  days  from  meningeal 
hemorrhage  due  to  protracted  instrumental  delivery,  from 
diseases  of  the  brain  as  meningitis,  or  tumors,  onset  of  acute 
infections  in  place  of  a  chill ;  may  be  reflex  from  an  undigested 
meal ;  may  be  due  to  toxemia — either  from  intestinal  auto- 
intoxication or  uremia ;  frequently  seen  in  rickets  and  in 
exhausting  diseases,  from  injury,  and  in  epilepsy,  which  will 
be  considered  separately.  Convulsions  are  most  frequent 
under  two  years  of  age. 

Pathology. — There  are  many  theories.  The  convulsion 
is  produced  by  irritation  of  the  cortical  cells  of  the  brain  either 
directly,  reflexlv,  or  from  toxic  substances  in  the  blood.  A 
convulsion  is  to  be  regarded  as  a  symptom  of  some  patho- 
logic condition. 

"Symptoms. — In  many  cases  there  are  initial  cry,  devia- 
tion of  the  eyes,  loss  of  consciousness,  tonic  or  clonic  mus- 
cular spasms,  and  the  involuntary  passage  of  urine  and  feces. 
A  convulsion  is  often  seen  in  a  child  where  an  adult  would 

have  a  chill. 

]STo  two  convulsions  are  alike,  but  there  is  no  difficulty 
in  recognizing  one.  Following  a  convulsion  the  child  may 
be  dazed,  or  even  remain  unconscious  for  some  time.  Sev- 
eral convulsions  may  follow  one  another  in  rapid  suc- 
cession. Death  may  take  place  from  asphyxiation  or 
exhaustion. 

Diagnosis. — The  convulsion  itself  is  easily  recognized. 
The  cause  may  be  difficult  to  determine.  A  convulsion 
coming  on  without  previous  illness  is  usually  functional.  ^  A 
general  convulsion  is  usually  functional ;  a  partial  convulsion 

1  H  H.  Scott.  "Convulsions,  Causation  of,"  Practitioner,  August,  1906, 
p.  237.  John  Thomson,  "Convulsions  in  Early  Infancy,"  Practitioner, 
October,  1905,  p.  510. 


302 


DISEASES  OF  INFANTS  AND   CHILDREN 


has  usually,  though  not  necessarily,  an  organic  cause.  A 
partial  convulsion  is  usually  evidence  that  the  corresponding 
part  of  the  brain  cortex  is  diseased.  The  history  of  im- 
proper feeding  may  help.  The  initial  convulsion  often  seen 
at  the  outset  of  an  acute  disease  is  generally  accompanied 
with  very  high  fever.  The  urine  should  be  examined  where 
possible.     (See  Epilepsy.) 

Prognosis. — Depends  on  the  cause.  Functional  convul- 
sions are  rarely  fatal  except  in  the  very  young  and  the 
rachitic.  A  convulsion  in  a  child  previously  healthy  is 
rarely  fatal.  A  convulsion  coming  on  late  in  any  severe 
disease  is  serious. 

Treatment. — Chloroform  to  quiet  the  convulsion,  wash 


Fig.  77.— Paraplegia.    Photographed  in  epileptiform  convulsion  (Peterson). 

out  stomach  and  bowel,  or  give  an  emetic  (teaspoonful  doses 
of  syrup  of  ipecac  repeated  every  fifteen  minutes  until 
effectual).  Hot  mustard  pack  or  bath.  Cold  applications 
to  the  head.  Chloral  or  chloral  and  bromid,  internally,  by 
mouth  or  rectum.  If  not  effectual  give  morphia  hypo- 
derm  ically.  (Six  months,  ^g-  gr.  ;  one  year,  -A^  gr. ;  two 
years,  -^  gr.)  Later  on  if  there  is  still  a  tendency  to  recur- 
rence an ti pyrin  or  phenacetin  and  bromids  may  be  given. 
Urethane  is  sometimes  used.  Inhalations  of  oxygen  may  be 
given  if  cyanosis  is  marked.  Calomel,  castor  oil,  or  salines 
may  be  used  to  clean  out  the  bowel. 


DISEASES  OF   THE  NERVOUS  SYSTEM.  303 

FPILEPSY.1 

(Falling  Sickness.  J 

Definition. — Periodic  attacks  of  unconsciousness,  with 
or  without  convulsions.  Usually  divided  into  grand  rual — 
major  epilepsy — and  petit  mal — minor  epilepsy. 

Jacksonian  Epilepsy. — This  is  confined  to  a  group  of 
muscles,  sometimes  called  "  symptomatic,"  as  it  denotes  brain 
disease. 

Psychic  Epilepsy. — A  temporary  loss  of  consciousness, 
without  other  manifestations. 

Etiology. — It  may  be  hereditary.  A  neurotic  taint  in 
a  family  may  appear  in  the  form  of  epilepsy.  Reflex  con- 
vulsions from  any  cause  if  frequently  repeated  may  cause 
epilepsy.  May  begin  very  early  in  life,  usually  between 
ten  and  twenty  years.  It  may  follow  the  acute  diseases 
of  childhood.    .  It  may  follow  injury. 

Pathology. — Probably  due  to  degenerative  changes  in 
the  cerebral  cortex. 

Symptoms. — Grand  Mal. — Often  preceded  by  a  warning 
sensation  called  an  aura,  which  may  be  a  feeling  in  a  mem- 
ber or  of  special  sense.  There  is  a  cry ;  the  patient  falls  in 
a  violent  tonic  spasm.  This  is  followed  by  a  clonic  spasm, 
which  passes  off.  The  patient  may  remain  unconscious  for  a 
short  or  long  time  after  the  convulsion,  and  on  recovery  com- 
plain of  muscular  weakness  and  mental  confusion.  Some- 
times the  patient  is  apparently  conscious  and  comes  to 
himself  later  with  no  recollection  of  what  he  has  done. 
There  may  be  maniacal  attacks  after  a  fit.  The  face  is  pale 
at  the  outset  and  the  pupils  contracted ;  later  the  face  becomes 
cyanosed  and  the  pupils  dilate.  The  tongue  is  frequently 
bitten. 

Petit  Mal. — The  attack  may  consist  of  a  transitory  pallor, 
with  or  without  twitching  of  the  muscles,  sometimes  involun- 
tary urination.  The  lapse  in  consciousness  may  be  but  a  few 
seconds  long. 

1  Smith,  "  Epilepsy,"  Lancet,  January  24,  1903,  p.  221. 


304  DTSEASES  OF  INFANTS  AND   CHILDREN. 

Between  these  two  forms  there  are  all  grades  of  se- 
verity. 

Status  epilepticus  is  a  condition  in  which  the  seizures  fol- 
low one  another  rapidly  without  any  intervening  return  of 
consciousness.  - 

In  epilepsy  there  is  sooner  or  later  mental  deterioration, 
and  stigmata  of  physical  degeneration  are  frequently  pres- 
ent. 

Diagnosis. — From  Organic  Brain  Disease. — The  con- 
vulsions are  liable  to  be  limited  to  a  group  or  groups  of 
muscles.  Other  evidences  of  brain  lesions  are  frequently 
present. 

Hysteria. — By  the  nature  of  the  seizure,  stigmata  of 
hysteria,  and  absence  of  injury  on  falling,  tongue  is  not 
bitten,  etc. 

Uremia. — History  and  examination  of  urine. 

Epilepsy  attacks.  Fainting  spells.  Hysterical  attacks. 

Loss  of  consciousness  very    Loss      of      consciousness    Loss  of  consciousness  not 

sudden.  gradual.  absolute. 

Warning   of  short     dura-    Warning  of  some  minutes    The  attack  often  preceded 
tion.  before  consciousness  is       by     emotional     excite- 

lost.  ment. 

Pupils  dilated  ;  do  not  con-    Pupils  contracted   or   un-    Pupils  not  dilated. 

tract  to  light.  altered. 

Tonic  and  clonic  spasms    Pulse  feeble  ;  no  spasms.       Tonic    rigidity  ;    exagger- 
in  various  parts  of  the  ated     conscious    move- 

body,  ments;  arching  of  back  ; 

excessive  noises. 
Bloody  foam  at  the  mouth.    No  evident  biting  of  the 

tongue. 
Involuntary  passage  of  the    No  involuntary  passage  of    No  involuntary  passage  of 
urine  and  feces  urine  or  feces  excepting       urine  or  feces. 

in  rare  instances. 
Prolonged  stupor  after  the  Recovery      gradual ;      no 

attacks.  stupor.  The  patient  may 

pass,     however,    into    a 
trance  condition. 
Tonic  and  clonic  spasm.  Attacks      may     be       fre- 

quently repeated. 
Attacks  not  frequent,  as  a    Recovery  prompt  after  at-    Duration'    of    the    attack 
rule.  tack.  much     longer    than   in 

epilepsy. 

Prognosis. — Usually  bad,  but  is  benefited  by  treatment, 
and  cases  seen  early  where  convulsions  are  brought  on  by 
dietetic  errors  can  often  be  relieved  entirely. 

Treatment. — Remove  all  sources  of  irritation,  as  ade- 
noids, phimosis,  etc.     Good  hygiene,  open-air  life,  with  mod- 


DISEASES   OF   THE  NERVOUS  SYSTEM. 


31  >5 


erate  exercise   and    pleasant   occupation.      Careful   feeding, 

meat  but  once  a  day,  and  not  more  food  than  patient  can 
assimilate.  Avoid  constipation.  Intestinal  antiseptics,  sodium 
salicylate  or  salol  may  be 
of  value.      Bromids  arc  of 

decided  value  in  control- 
ling- the  seizures.  Pro- 
portionately larger  doses 
are  required  for  children 
than  for  adults.  Tonics 
should  be  used  when  indi- 
cated. Clonic  spasms  can 
sometimes  be  suppressed 
and  consciousness  restored 
by  placing  the  epileptic  on 
his  left  side  during  the 
tonic  spasm. 


/ 


TETANY.1 


<ittk 


/ 


Fig.  "S — Infant  »s-ith  mild  attack  of 
tetany,  showing  characteristic  spasmodic 
position  of  hands  and  feet  i Church). 


Definition. — A  condi- 
tion characterized  by  tonic 
muscular  spasm,  intermit- 
tent or  continuous.  The 
hands  and  feet  are  affected 
most  (carpopedal  spasm). 

Etiology. — Usually  under  two  years  of  age ;  frequently 
associated  with  rickets,  sometimes  with  marasmus,  diarrhea. 
and  other  diseases. 

Pathology. — Unknown.  Probably  in  some  cases  due 
to  disease  of  the  parathyroid  bodies. 

Symptoms. — Gradual  or  suddeu  onset.  Convulsions 
are  frequent.  The  extremities  become  spastic.  The  wrist 
is  flexed  to  a  right  angle,  the  fingers  are  flexed  at  the  meta- 
carpal joint  and  are  straight,  the  thumb  in  extreme  adduction 
(main  accoucheur).     The  feet  are  in  an  equinovarus  position. 

1J.  P.  Crozer  Griffith.  ''Tetany  in  America,"  American   Journal  of  the 
Medical  Sciences,  1895.     C.  P.  Howard,   "Tetany,"  American  Journal  of  the 
Medical  Sciences,  February,  1906,  p.  301. 
20 


306  DISEASES  OF  INFANTS  AND   CHILDREN. 

Wrists  and  ankles  stiff;  elbows,  shoulders,  knees,  and  hips 
usually  freely  movable.  Spasm  of  the  glottis  is  often  pres- 
ent. Deep  and  superficial  reflexes  are  exaggerated.  Pres- 
sure upon  the  nerves  or  arteries  produces  spasm  of  parts  sup- 
plied (Trousseau's  Symptom).  Percussion  over  nerve  causes 
contraction  in  muscle  supplied ;  especially  marked  in  the 
facial  nerve  (Chvostek's  Symptom).  Pain  is  often  present. 
Lasts  days  or  weeks. 

Diagnosis, — Characteristic  attitude.  Trousseau's  and 
Chvostek's  symptoms  make  diagnosis  easy.  From  menin- 
gitis by  absence  of  brain  symptoms,  from  tetanus  by  absence 
of  or  only  slight  trismus. 

Prognosis. — Usually  good. 

Treatment. — Empty  intestinal  tract.  Give  vermifuges. 
Hot  baths  and  frictions  for  the  spasm.  Chloral,  bromids,  or 
anti pyrin  may  be  used  to  combat  the  spasm.  Calcium  lactate 
has  been  suggested. 

LARYNGISMUS  STRIDULUS. 

Definition. — A  spasm  of  the  larynx,  frequently  seen  in 
children  who  have  rickets  or  tetany. 

Etiology. — It  is  most  frequently  seen  in  boys  from  six 
months  to  two  years  of  age,  and  almost  invariably  there  are 
symptoms  of  rickets  and  often  the  history  of  convulsions. 
The  spasm  may  be  precipitated  by  excitement  or  exposure  to 
cold. 

Symptoms. — The  spasm  comes  on  suddenly,  the  child 
looks  frightened,  the  muscles  become  stiffened,  the  chest 
fixed  usually  in  expiration,  the  face  becomes  cyanosed,  and  if 
the  spasm  lasts  very  long  there  may  be  an  ashy  pallor.  In 
some  instances  there  may  be  a  short  loss  of  consciousness 
and  a  convulsion.  Sometimes  there  is  no  crowing  sound. 
The  attacks  vary  greatly  in  severity,  are  most  frequent  at 
night,  and  there  may  be  only  an  occasional  one  or  as  many 
as  twenty  a  day. 

Diagnosis. — Usually  eas}^.  From  catarrhal  spasm 
(false  croup)  by  the  frequency,  shortness,  and  character  of 
the    attacks   and    the    younger   age.      (See    also  Whooping- 


DISEASES  OF  THE  SERVO  US  SYSTEM. 


307 


cough.)  If  there  is  Chvostek's  sign,  tetany,  or  the  history 
of  convulsions,  a  doubtful  case  may  be  regarded  as  one  of 
laryngismus.      (See  also  Epilepsy.) 

Prognosis. — Usually  good.  Exceptionally  death  takes 
place  in  an  attack.  Coming  on  in  the  course  of  an  acute 
disease  it  is  a  bad  sign. 

Treatment. — Antispasmodics,  as  chloral,  bromid,  and 
antipyrin,  are  the  most  useful  drugs  if  the  attacks  are  fre- 
quent. Inhalation  of  chloroform  may  be  needed  to  stop  the 
spasm  in  exceptional  cases.  Smelling-salts  may  be  tried.  In 
the  intervals,  cod-liver  oil,  out-of-door  life,  and  an  anti- 
rachitic diet  may  be  used.  The  bowels  should  always  be 
kept  open. 

CHOREA. 

(Saint  Vitus'  Dance;  Sydenham's  Chorea.) 
Definition, — A  disease  characterized  by  irregular  invol- 
untary movements   of  the  muscles,  often  slight  mental  dis- 
turbance, and  frequently  endocarditis. 


Fig.  79.— Facial  expression  in  chorea.        Fig.  80.— Facial  expression  in  chorea. 

Etiology. — Most  often  in  girls  between  five  and  fifteen 
years  of  age.     Often  associated  with  rheumatism.     It  may 


308  DISEASES  OF  INFANTS  AND   CHILDREN. 

follow  other  infectious  diseases.  It  may  also  be  due  to  over- 
work at  school  or  in  factories. 

Pathology. — There  is  no  constant  lesion  in  the  nervous 
system.     Endocarditis  is  often  present. 

Symptoms.  —  Child  first  noticed  to  be  nervous,  stum- 
bles, and  is  awkward ;  then  marked  purposeless  movements 
of  any  or  all  the  muscles.  There  may  be  difficulty  in  talk- 
ing plainly.  There  is  marked  muscular  weakness.  Symp- 
toms of  rheumatism  are  associated  in  some  cases.  Anemia  is 
usually  marked.  The  reflexes  are  usually  normal,  but  may 
be  increased  or  diminished.  With  proper  treatment  it  lasts 
about  six  weeks.     There  is  a  tendency  to  relapse.     Without 


Fig.  81.— Facial  expression  in  chorea. 

proper  treatment  it  lasts  months  and  tends  to  recur.  In  rare 
cases  the  disease  is  unilateral. 

Diagnosis. — Usually  easy,  but  care  should  be  taken 
not  to  mistake  athetosis  for  this  disease. 

Prognosis. — As  a  rule,  good. 

Treatment. — During  acute  stage  rest  in  bed  ;  if  possible, 
isolation  with  a  nurse  who  is  a  stranger.  Milk  diet,  and 
later  a  good,  plain,  nutritious  food.  Regulate  the  bowels. 
Iron  or  arsenic  may  be  given,  and  where  rheumatic  symp- 
toms are  present,  salicylates.  Antipyrin  and  strychnia  are 
also  used.  The  rest  and  feeding  are  more  important  than 
drugs. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  300 

OTHER  SPASMODIC  AFFECTIONS.' 

Habit  Spasm. — The  repetition  of  some  movement  a 
great  number  of  times  from  habit;  usually  seen  in  neurotic 
children.  Frowning  and  winking  are  frequently  seen.  May 
be  difficult  to  differentiate  from  tics. 

Athetosis  and  Athetoid  Movements. — These  are 
usually  seen  in  diplegias  and  hemiplegias,  but  may  be  seen 
as  the  only  symptom.  Movements  are  irregular  and  chorei- 
form in  character.  Some  rigidity  is  present.  Athetosis  is 
not  affected  by  treatment. 


Fig.  82.— Athetoid  movements. 

Rotary  and  Nodding  Spasm. — A  rare  disease  seen 
in  infants,  usually  between  the  third  and  eighteenth  month. 
Consists  in  either  rotary  or  nodding  movements  of  the  head, 
which  stop  if  the  eyes  are  bandaged.  Nystagmus  is  fre- 
quently associated.  Usually  gets  well  after  several  months. 
If  severe,  bromids  may  be  given. 

Nystagmus. — This  is  a  peculiar  oscillation  of  the  eye- 
ball, most  noticeable  on  moving  the  eye.     It  may  be  vertical 

1  Spiller,  "  Treatment  of  Spasticity  and  Athetosis  by  Resection  of  Pos- 
terior Spinal  Roots,"  American  Journal  of  the  Medical  Sciences,  June,  1910, 
p.  822.  G.  F.  Still,  "  Habit  Spasm  in  Children/'  Lancet,  December  16, 
1905,  p.  1754. 


310  DISEASES  OF  INFANTS  AND   CHILDREN. 

or  horizontal.  Jerking  movements  of  the  eyeballs  may  also 
be  seen  in  idiots  and  in  children  with  squint. 

Nystagmus  is  seen  in  multiple  sclerosis,  in  Friedreich's 
ataxia,  and  sometimes  in  spastic  diplegia,  meningitis,  and 
hydrocephalus,  It  is  also  seen  in  diseases  of  the  eye,  cho- 
roiditis, corneal  opacity,  and  other  diseased  conditions  where 
the  sight  is  aifected. 

Spasmus  nutans  or  nodding  spasm  is  characterized 
by  nystagmus.  This  is  a  peculiar  condition  in  which  there 
is  a  nodding  of  the  head.  It  comes  on  between  the  sixth 
month  and  second  year,  lasts  several  weeks  or  several  months, 
and  then  recovery  takes  place. 

Rhythmic  jerking  of  the  head  during  sleep  may  also  be 
met  with. 


Fig.  83— Athetosis  of  feet  (Church). 


Hiccough.  (Singultus). — Spasm  of  the  diaphragm,  usually 
due  to  disturbances  of  the  stomach,  occasionally  to  other 
causes. 

Expel  gas  from  stomach  ;  holding  the  breath,  drinking 
water,  or  producing  sneezing  by  tickling  the  nose  with  a 
feather  may  stop  an  attack.  Chloral  is  useful  in  persistent 
cases. 

Thomsen'S  "Disease1  (Congenital  Myotonia). — A  family 
hereditary  disease  in  which  the  muscle  becomes  rigid  on  being 

1  Haberman,  "  Myatonia  Congenita  of  Oppenheim,  or  Congenital  Atonic 
Pseudoparalysis,"  Amer.  Jour.  Med,  ScL,  vol.  cxxxix.,  1910,  p.  383. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


311 


moved.     After    several    movements    the   spasm    passes    off. 
Improved  by  muscular  exercise.     It  is  incurable. 

Cervical  Opisthotonos  or  Retraction  of  the 
Head. — This  is  most  marked  in  posterior  basic  meningitis 
and  cerebrospinal  fever,  but  is  also  seen  in  tuberculous  men- 


Fig.  84. — Extreme  opisthotonos. 

ingiiis.  It  may  be  noted  in  many  other  conditions  when  the 
meninges  are  not  affected,  as  acute  middle-ear  disease,  in 
severe  marasmus,  in  the  acute  infectious  diseases,  in  acute 
diarrheal  diseases,  in  chronic  hydrocephalus,  and  cerebellar 
tumor.  It  may  be  seen  in  caries  of  the  spine  and  in  retro- 
pharyngeal abscess. 

Torticollis1  (Wry-neck). — Usually  caused  by  a  spasm  of 
the  sternomastoid  muscle ;  sometimes  the  cervical  muscles 
and  trapezius  are  also  involved.  The  head  is  drawn  to  one 
side.  If  the  posterior  muscles  of  both  sides  are  affected  the 
head  is  drawn  backward.     It  is  caused  by  irritation  of  the 

•   *■  A.  H.  Tubby,  "  Torticollis  or  Wry-neck,"  British  Medical  Journal,  June 
16,  1906,  p.  1387. 


312 


DISEASES  OE  INFANTS  AND   CHI  LUMEN. 


eleventh  nerve,  and  it  may  be  congenital  or  acquired.  It 
may  be  caused  by  enlarged  glands,  or  exposure  to  cold  or 
rheumatism.  The  prognosis  depends  on  the  cause.  The 
acute  cases  are  favorable ;  the  congenital  unfavorable. 

Treatment. — Remove  the  cause  if  known,  anti-rheumatic 
remedies  in  rheumatic  cases  ;  heat,  massage,  and  injections 
of  atropin  may  all  be  of  service.  Old  cases  require  surgical 
treatment  and  orthopedic  supports. 


„ ..  y&mm***-.  -■     ■  ._Jm 


Fig.  85.— Congenital  torticollis  (Moore). 


Huntington's  Chorea  (Hereditary  Chorea). — A  rare 
disease,  mentioned  here  because  hereditary.  It  usually  comes 
on  between  thirty  and  forty  years  of  age  in  some  of  the 
members  of  affected  families.  There  is  a  coarse,  grimacing 
chorea  with  gradual  mental  deterioration. 


HYSTERIA. 


This  is  occasionally  seen   in  childhood,  usually  not  until 
after  the  ninth  or  tenth  year.     The  causes,  symptoms,  and 


DISEASES  OF  THE  XERVOUS  SYSTEM.  313 

treatment  are  the  same  as  in  adults.  Any  disease  may  be 
simulated,  and  hysteria  may  be  overlooked  because  the  phy- 
sician may  ignore  its  occurrence  in  children.  Isolation  or 
removal  from  the  home  is  nearly  always  essential  in  the 
successful  treatment  of  these  cases. 

TIC 

These  are  complex  movements;  always  of  some  definite 
character.  These  movements  are  repeated  at  intervals  ;  occa- 
sionally they  are  continuous.  They  usually  occur  in  children 
with  organic  brain  lesions  or  malformations,  but  may  also 
occur  in  otherwise  apparently  healthy  children.  They  may 
be  regarded  as  a  neurosis.  The  treatment  is  liable  to  be 
unsatisfactory. 

Convulsive  Tic.-— Convulsive  twitching  of  the  muscles 
— usually  one  group  of  muscles  or  convulsive  movements  of 
some  regular  kind,  often  associated  with  making  certain 
sounds  or  repeating  certain  words  (echolalia)  or  the  involun- 
tary utterance  of  obscene  or  profane  language.  It  is  a  very 
chronic  disease,  and  the  prognosis  is  not  very  favorable. 

Treatment. — Young  patients  should  be  isolated  and  taught 
self-control.  Opiates  may  be  necessary  if  sleep  is  interfered 
with  ;  hvoscine  has  been  advised. 

HEADACHE. 

Headache  is  due  to  many  causes.  Persistent  and  recur- 
rent headaches  often  cause  a  special  expression,  "  a  look  of 
depression,  heaviness,  and  fulness  about  the  eyes,  especially 
about  the  under  eyelids  :  this  sign  is  usually  bilateral,  and  is 
due  to  a  relaxed  condition  of  the  muscle  (orbicularis)  which 
surrounds  the  eyelids  "  (Warner).  This  expression  may  dis- 
appear momentarily  if  the  patient  is  made  to  laugh. 

In  very  young  children  headache  is  usually  associated 
with  meningitis,  brain  tumor,  and  other  organic  diseases.  In 
older  children  the  more  common  causes  of  headache  are  ade- 

lC  Herrman,  "Tics  in  Children,"  Archives  of  Pediatrics,  June,  1906, 
p.  426. 


314  DISEASES  OF  INFANTS  AND  CHILDREN. 

noids,  errors  of  refraction  and  eye  strain,  digestive  disturb- 
ances, toxemia,  caries  of  the  teeth,  anemia,  malnutrition, 
rheumatism,  malaria,  fever,  gout,  uremia,  hysteria,  epilepsy, 
meningitis,  and  brain  tumor. 

DISORDERS  OF  SLEEP. 

The  normal  child  sleeps  soundly.  With  but  few  excep- 
tions restlessness  and  sleeplessness  are  indications  of  disease 
or  pain.  Digestive  disturbances,  fevers,  and,  in  fact,  any  dis- 
eased condition  may  be  a  cause.  Poor  ventilation,  over- 
heated or  too  cold  rooms,  and  improper  training  are  frequent 
causes.     Real  insomnia  is  sometimes  met  with. 

Pavor  Nocturnus l  (Night  Terrors). — A  curious  con- 
dition in  which,  after  sleeping  soundly  for  several  hours,  the 
child  wakens  in  a  condition  of  terror.  This  continues  for 
some  time,  during  which  the  child  cannot  be  comforted  and 
does  not  seem  to  understand.  It  may  regain  consciousness 
or  drop  off  to  sleep.  Night  terrors  are  most  common  from 
three  to  eight  years  of  age,  and  are  most  frequent  in  neurotic 
children.  Overstudy  and  exciting  "  dime  novels  "  are  com- 
monly the  most  frequent  causes.     It  is  usually  outgrown. 

Treatment. — Careful  hygiene  of  the  nervous  system,  out- 
of-door  life,  avoidance  of  excitement,  are  all  important.  Seda- 
tives, such  as  bromids,  chloral,  and  antipyrin,  are  useful  in 
severe  cases. 

Day  Terrors.2 — Attacks  similar  to  night  terrors  may 
occur  during  the  waking  hours,  and  these  are  more  serious 
than  the  above. 

Somnambulism  (Sleep-walking). — This  is  not  uncom- 
mon in  children.  The  individual  goes  through  a  series  of 
purposeless  actions,  such  as  walking  about,  closing  doors  or 
windows,  while  sound  asleep,  and  retains  no  consciousness  of 
what  he  has  done.  It  is  frequently  associated  with  night- 
mare, due  to  errors  in  diet. 

1  Coutts,  "  Night-mare  and  Night  Terrors,"  American  Journal  of  the  Med- 
ical Sciences,  February,  1895. 

2 Still,  "Day  Terrors,"  Lancet,  February  3, 1900. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  315 

SPEECH  DISTURBANCES.1 

These  may  be  due  to  organic  brain  diseases,  as  the  difficult 
speaking  in  cerebral  diplegia,  or  to  functional  disturbances. 
These  latter  are  more  common  in  boys  than  girls.  Func- 
tional speech  disorders  may  be  regarded  as  stigmata  of  degen- 
eration ;  other  stigmata  are  usually  present. 

Stuttering. — Stuttering  is  due  to  an  excessive  innerva- 
tion of  the  vocal  muscles,  producing  cramps  of  the  muscles  of 
breathing,  and  sometimes  hypertouicity  of  the  laryngeal 
muscles,  and  sometimes  also  of  the  muscles  of  pronunciation. 
Sometimes  the  excessive  nervous  energy  causes  movements 
of  other  muscles,  so  that  the  face  may  be  contorted  or  there 
may  be  abrupt  irregular  movements  of  the  arms  or  even  of 
the  entire  body.  The  voice  is  usually  monotonous,  the 
articulation  is  good,  but  there  is  difficulty  in  continuous 
speech.  There  is  often  hesitancy  and  repetition  of  a  syllable 
several  times  before  the  next  one  can  be  said.  It  may  be 
inherited  or  acquired  by  imitation,  or  it  may  come  on  after 
acute  illnesses.  The  acute  cases  usually  recover,  and  the 
others  may  be  overcome  in  many  cases  by  systematic  train- 
ing by  a  skilful  teacher. 

Stammering".2 — Often  used  synonymously  with  the  pre- 
ceding, but  better  limited  to  cases  where  articulation  is  im- 
perfect; frequently  (not  always)  due  to  deformity.  Treat- 
ment is  to  correct  the  deformity  and  train. 

Nasal  Speech  is  due  to  adenoids,  enlarged  tonsils,  nasal 
obstruction,  and  many  American  children  seem  to  use  a  dis- 
agreeable nasal  twang.  Sudden  onset  of  nasal  speech  is  due 
to  inflammation  of  the  throat  or  paralysis  of  the  soft  palate. 

I/isping".3 — Imperfect  formation  of  certain  sounds,  often 
of  s.    It  is  common  in  young  children  and  generally  outgrown. 

falling  is  a  term  applied  to  very  marked  lisping,  and  in 
older  children  it  indicates  mental  deficiency. 

Alalia. — Inability  to  talk ;  in  older  children  usually 
associated  with  mental  disturbance. 

1  Wyllie,  "The  Disorders  of  Speech,"  Edinburgh,  1894. 

2  Laugwillj  "  Stammering  and  its  Treatment  by  the  General  Practi- 
tioner," Practitioner,  January,  1903. 

3Ashby,  "Lisping,"  Medical  Chronicle,  October,  1903,  p.  1. 


310  DISEASES  OF  INFANTS  AND   CHILDREN. 

Backwardness. — Seen  in  untrained  children,  as  in  over- 
crowded asylums,  etc. 

Functional  Aphasia. — This  may  be  associated  with 
mental  deficiency,  chorea,  hysteria  from  fright,  etc. 

Idioglossia. — A  curious  form  of  speech  disturbance 
usually  occurring  in  children  who  are  normal  mentally. 
There  is  marked  killing  with  the  substitution  of  t,  d,  or  n  or 
some  other  easily  pronounced  letter  for  all  syllables  with 
which  difficulty  is  experienced.  Those  accustomed  to  the 
child  may  understand  it,  others  cannot. 

Treatment  of  Speech  Defects. — Stuttering. — The 
shallow,  ill-managed  respiration  which  is  frequently  seen 
should  be  corrected  by  systematic  breathing  exercises  which 
should  be  carried  out  daily.  If  there  is  any  obstruction  to 
the  respiration  it  should  be  removed.  The  child  should  be 
taught  to  speak  from  a  well-filled  chest,  and  not  to  use  the 
reserve  air,  and  must  be  taught  to  speak  with  a  resonant  and 
modulated  voice  instead  of  the  low  muttering  intonation 
usually  adopted,  but  it  should  not  be  allowed  to  shout.  It 
should  be  taught  to  speak  slowly  and  distinctly,  making  all 
the  consonants  clear.  The  child  should  be  taught  to  sing 
sentences  instead  of  speaking  them,  so  as  to  introduce  a  new 
method  of  speaking,  and  also  to  modulate  the  voice.  Attempts 
should  be  made  to  make  the  child  talk  with  expression  and 
to  distract  the  mind  from  the  idea  that  he  must  stutter ;  for 
this  last  beating  time  forcibly  with  the  hand  may  be  employed. 

Treatment  of  Other  Defects. — The  following  alphabet 
will  be  found  of  great  use  in  locating  quickly  the  seat  of  the 
trouble,  and  the  methods  to  correct  them  as  suggested  by 
Scripture1  will  be  found  of  value  : 

WYLLIE'S  PHYSIOLOGIC  ALPHABET. 

I. — Vowels. 

(y — i  e  a  o  u — w.) 

These  should  be  pronounced  in  the  Latin  manner,  as  ee, 
eh,  ah,  oh,  oo.    y  and  w  are  consonants,  not  vowels,  but  have 

1  Medical  Record,  March  21,  1908;  Ibid,  August  15,  1908;  and  Gutz- 
mann,  Sprache  und  Sprachfehler,  Leipzig,  1894. 


p 

B 

(W 

W 

F 

V 

Th1 

Th'2 

S 

Z 

Sk 

Zk 

T 

D 

(L) 

L 

R 

K 

G 

H  or  Ch 

Y 

(B) 

N 


DISEASES   OF  THE  NERVOUS  SYSTEM.  317 

very  close   relationships  to  the  vowels,  initial  y  being  very 
closely  related  to  i  and  initial  w  to  it. 

II. — C<  >NS<  >.\"A  NTS. 

Voiceless  oral     Voiced  oral      Voiced  nasal 
consonants.       consonants.       resonauts. 

Labials  P  B  M 

(First  stop  position) 

Labiodentals 

Linguodentals 

Anterior 
Linguopalatals 

(Second  stop  position) 

Posterior  K  G  ~Sg 

Linguopalatals 

(Third  stop  position) 

Lip  Defects. — Instead  of  W  some  children  say  V.  In  say- 
ing Tthe  lower  lip  is  brought  against  the  upper  lip,  and  for 
IF  the  two  lips  are  brought  near  each  other.  To  change  the 
Vto  W,  instruct  the  patient  to  say  "wood"  or  "war,"  and 
just  as  he  begins  press  the  lower  lip  down  with  the  linger. 

Tongue  Defects. — 1.  " S—T"  Lisping. — The  patient  says 
"  toup  "  for  "  soup,"  etc.  When  "  8  "  is  said  the  tip  of  the 
t<  >ngue  is  brought  against  the  palate,  but  a  small  space  is  left 
through  which  the  air  may  be  blown.  In  this  form  of  lisping 
the  patient  presses  his  tongue  too  hard,  closing  the  air  chan- 
nel, and  "  T"  results.  The  treatment  for  this  is  to  insert  a 
probe  just  over  the  middle  of  the  tongue  and  press  it  down 
just  as  the  patient  tries  to  say  "  T"  thus  making  an  air- 
space and  changing  it  to  "  S." 

2.  "TH-T"and  "  TH-D"  Lisping.— This  is  a  very 
common  defect,  the  children  saying  "tin"  for  "thin"  and 
"dis"  for  "this,"  etc.  In  both  cases  in  saying  "th"  the 
tongue  is  placed  against  the  palate,  but  so  slightly  that  air 
escapes  from  both  sides.  The  lisping  conies  from  too  much 
pressure  of  the  tongue.  The  treatment  is  to  place  a 
probe  at  the  side  of  the  mouth,  and  when  the  patient  says 
"t,"  press  down  the  tongue  at  the  side  and  he  is  forced  to 
say  "th." 


318  DISEASES  OF  INFANTS  AND   CHILDREN. 

3.  "  S-TH"  Lisping. — An  interchange  of  sounds  due  to 
the  tongue  not  rising  sufficiently  at  the  edges  in  front  to  cut 
off  the  air  at  the  sides  while  having  a  small  channel  in  the 
middle.  This  is  the  form  present  when  there  is  tongue-tie. 
If  the  frenum  is  too  short  it  should  be  cut.  The  treatment 
is  the  same  as  for  No.  1. 

4.  "T-TIL"  Lisping. — "Wather"  is  said  for  "water," 
etc.,  due  to  the  failure  to  cut  off  the  air  with  the  tip  of  the 
tongue  firmly  against  the  palate.  It  is  usually  sufficient  to 
explain  the  formation  of  the  two  sounds. 

5.  "R"  Defects. — "  W"  is  used  in  place  of  "r,"  and  the 
patient  must  be  taught  how  to  get  the  tongue  in  the  right 
place  to  say  "r."  He  may  be  taught  to  roll  the  (<rv  as  in 
French  ;  if  this  fails,  have  him  repeat  words  which  bring 
the  tongue  in  approximately  the  same  position,  as  u  sun,  run, 
sun,  run,"  or  "  tun,  run,  tun,  run,"  etc. 

6.  Various  Substitutes. — "  T"  may  substitute  for  "  k" 
but  not  in  all  words,  and  this  is  usually  due  to  negligence. 
Have  the  patient  repeat  the  "  k "  sound  before  various 
vowels,  and  then  pass  over  to  the  incorrect  word,  as  "  kat, 
kat,  kat,  ka-ka-kan,  ka-ka-,  ka-kandy."  In  cases  where  the 
velum  action  is  defective  the  patient  must  be  taught  to  say 
"p,  6,  t,  d,  .  .  .  a,  o"  without  passing  air  through  his 
nose.  A  rubber  tube  with  a  nose  tip  on  one  end  and  a  glass 
tube  on  the  other  is  held  in  a  support,  so  that  the  glass  tube 
end  is  just  in  front  of  a  candle  flame.  If  the  air  passes 
through  the  nose  the  flame  moves.  Playing  on  a  mouth 
harmonica  may  help  in  severe  cases. 

laryngeal  Defects. — Laxness  of  the  vocal  cords  is 
frequently  noted  both  in  persons  with  other  defects  and  in- 
dependently. There  is  defective  closure  of  the  glottis,  and 
this  may  be  overcome  by  staccato  singing  and  practising 
notes  on  the  vowel  ah. 

laryngeal  Monotony. — This  is  seen  in  epileptics  and 
others.  The  voice  does  not  rise  and  fall  normally.  This 
may  often  be  overcome  by  explaining  the  difference  to  the 
patients  and  having  them  practice. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  319 

THE  INJURIOUS  HABITS  OF   INFANCY  AND   CHILDHOOD. 

Sucking. — Sucking  the  fingers  is  very  common  in  hun- 
gry infants  and  is  natural.  Continued  sucking  of  the  fingers 
or  toes,  of  a  "pacifier,"  or  of  a  nipple  is  a  bad  habit;  usually 
easily  overcome  if  taken  early,  and  difficult  to  control  if 
allowed  to  run  on.  It  may  lead  to  the  habit  of  masturbation 
later  on,  and  may  cause  deformities  of  the  jaws  and  fingers 
as  well  as  eczemas  and  infections.  Sucking  the  hands  may 
be  a  cause  of  chronic  vomiting.  Other  bad  habits  are  biting 
the  nails,  picking  at  the  face  or  hands,  eating  dirt  (pica),  and 
making  various  movements  with  the  head,  arms,  legs,  or  body. 

Treatment. — The  hands  may  be  covered  with  mittens,  tied 


Fig.  86. — Deformity  caused  by  thumb-sucking.    (Darby,  in  Keating's  Cyclopedia  of 

the  Diseases  of  Children.) 

into  long  sleeves  or  buttoned  under  the  jacket.  Splints  may 
be  resorted  to  in  aggravated  cases. 

Masturbation. — Definition. — The  habit  of  producing 
sexual  excitement  by  rubbing  the  genitalia  or  other  parts  of 
the  body. 

Etiology. — It  may  be  practised  by  very  young  infants, 
even  as  early  as  the  eighth  month.  Girls  and  boys  are  both 
affected.  It  may  be  started  by  rubbing  to  allay  irritation 
caused  by  uncleanliness,  inflammation,  etc.  If  the  habit  is 
formed  in  early  childhood  without  cause  it  may  be  regarded 
as  a  stigmata  of  degeneration.  It  may  be  taught  by  vicious 
nurses  or  other  children. 

Symptoms. — Friction  with  the  hands  against  some  object, 
or  by  holding  the  thighs  fixed  and  moving  the  body.  This 
is  followed  by  Hushing  of  the  face  and  relaxation.    The  chil- 


320  DISEASES  OF  INFANTS  AND   CHILDREN 

dren  are  liable  to  become  nervous,  and  later  may  develop  hys- 
teria or  other  functional  nervous  disorders.  In  older  children 
the  pupils  are  dilated,  the  palms  moist,  and  the  child  is  inat- 
tentive and  absent-minded. 

Prognosis. — If  the  cause  is  removed  early  the  outlook  is  fair. 

Treatment. — Early  recognition  and  close  observation  are 
the  most  important.  Remove  all  sources  of  irritation  and  do 
a  circumcision  if  necessary.  The  child's  moral  nature  should 
be  awakened  if  possible.  Out-of-door  life  and  a  building-up 
treatment  are  essential. 


ANGIONEUROTIC  EDEMA. 


A  rare  affection  sometimes  seen  in  children.  It  may  occur 
in  families  or  be  hereditary.  It  is  a  sudden  localized  edema 
which  may  jump  from  place  to  place.  Disappears  quickly. 
Frequent  attacks  may  occur.  Affected  individuals  should 
have  good  hygiene  and  tonic  treatment. 

EXOPHTHALMIC  GOITERS 
(Parry's  Disease;  Graves'  Disease;  Basedow's  Disease*) 

A  disease  characterized  by  rapid  heart  beat,  swelling  of 
the  thyroid,  and  protrusion  of  the  eyes.  It  is  very  rare  in 
childhood,  but  has  been  described. 

Enlargement  of  Thyroid  at  Pnberty. — Between 
twelve  and  fifteen  the  thyroid  may  enlarge  (in  girls),  and 
there  may  be  a  rapid  pulse  and  nervous  symptoms  suggestive 
of  exophthalmic  goiter.  This  condition  usually  rapidly  sub- 
sides by  the  use  of  rest,  good  feeding,  tonics,  and  fresh  air. 

MALFORMATIONS.3 

The  most  frequent  are  meningocele,  encephalocele,  and 
hydrencephalocele. 

1  T.  H.  Halsted,  "  Edema,  Angioneurotic,  of  Upper  Respiratory  Tract," 
American  Journal  of  the  Medical  Sciences,  November,  1905,  p.  863. 

2  Kocher,  "  Thyroid  Gland,  Pathology  of,"  British  Medical  Journal, 
June  2,  1906,  p.  1261.  A.  F.  Martin,  "  Thyroid  'Gland,  Significance  of 
Some  Enlargements  of,"  British  Medical  Journal,  Sept.  22,  1906,  p.  691. 

a  Ruhrah,  Archives  of  Pediatrics,  July,  1902. 


DISEASES   OF  THE  NERVOUS  SYSTEM. 


321 


Definition. — Meningocele.— A  protrusion  through  an 
opening  of  the  skull  of  the  brain  membranes.  The  sac  so 
formed  is  usually  filled  with  fluid. 

Encephalocele.— A  protrusion  of  part  of  the  brain  sub- 
stance. . 

Hydrencephalocele.— A  protrusion  of  the  brain  containing 
a  cavity  communicating  with  the  distended  lateral  ventricles. 

location.—  Thev  may  be  located  anywhere,  but  are 
most  frequently  in  the  median  line,  either  occipital  or  frontal. 
They  may  be  small  or  enormous  in  size.   _ 

Diagnosis. — In    meningocele    there    is    usually    a   small 


Fig.  87.— Exophthalmic  goiter. 


Yiq.  88.— Exophthalmic  goiter. 


tumor  at  birth  which  increases  in  size  ;  it  is  usually  pedun- 
culated, but  may  not  be.  The  tumor  is  smooth,  but  has  a 
distinctly  cystic*  feel.  It  fluctuates,  and  in  some  cases  is  re- 
ducible/or'  it  maybe  diminished  in  size  from  pressure.  It 
is  translucent,  if  the  tumor  is  not  too  large  nor  the  walls  too 
thick.  Pulsation  is  rare.  Pressure  usually  produces  cere- 
bral symptoms,  such  as  crying,  vomiting,  convulsions,  and 
stupor.  On  crying  or  forced  expiration  they  become  more 
tense.     The  skull  is  normal. 

In  eneephahceJe  there  is  a  small,  smooth  tumor,  pulsating 


21 


322  DISEASES  OF  INFANTS  AND   CHILDREN 

and  non-translucent.  It  is  rarely  pedunculated.  Pressure 
produces  cerebral  symptoms.  On  moderate  pressure  there  is 
no  pain,  malaise,  nor  reduction.  On  attempting  to^  effect 
reduction  by  harder  pressure  there  is  noted  dilatation  of 
the  pupil,  strabismus,  and,  more  rarely,  vomiting  and  con- 
vulsions. On  crying,  it  becomes  more  tense.  Pulsation 
synchronous   with   the    pulse   practically   always   means  en- 

cephalocele. 

In   hydrencephalocele   there    is    a   large    tumor,  generally 


w 


Fig.  89.— An  unusually  large  meningocele. 

pendulous,  pedunculated,  and  lobulated.  It  is  generally 
not  translucent  nor  reducible.  Fluctuation  is  present,  but 
pulsation  rarely.  Pressure  does  not,  as  a  rule,  produce 
symptoms.  On  crying,  it  is  made  only  slightly  more  tense. 
Very  large  tumors  are  practically  always  hydrencephalocele. 

From  other  tumors  by  their  growing  more  tense  on  crying. 

False  Meningocele.— A  cystic  tumor  following  injury  by 
the  history  of  an  injury  or  operation. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


323 


Prognosis. — Serious.  Almost  all  die  early.  A  few 
attain  old  age,  but  are  usually  weak-minded. 

Treatment. — Three  methods  are  used  :  (1)  Let  it  alone  ; 
(2)  aspirate  and  inject  an  iodin  mixture,  as  Morton's  solution  ; 


Fig.  90.— A  meningo-encephalocele. 


(3)  removal  by  excision.     This  latter  is  usually  preferred. 
Internal  hydrocephalus  may  follow  the  operation. 


BIRTH  PALSIES.1 

These  are  most  frequently  due  to  prolonged  pressure  during 
difficult  labor  or  to  artificial  delivery.     (See  also  p.  324.) 

Cerebral  Paralysis. — Most  of  these  hemorrhages  are 
meningeal  and  at  the  base  of  the  brain,  but  they  may  occur  from 
brain  laceration  or  from  depressed  fractures.  The  child  may 
he  born  dead  or  asphyxiated.  Convulsions  are  common. 
There  may  be  general  rigidity  or,  more  rarely,  general  relaxa- 
tion. The  pupils  are  frequently  contracted,  and  there  may 
be  oscillation  of  the  eyeballs.     Pulse  is  slow  and  weak,  and 

iGowers,  "  On  Birth  Palsies,"  Lancet,  vol.  i.,  1888,  p.  709.  Spiller, 
Frazier,  and  Van  Kaathoven,  "  Palsies,  Cerebral,  Spinal,  and  Peripheral, 
Treatment  of  Selected  Cases  of,"  American  Journal  of  the  Medical  Sciences, 
March,  1906,  p.  430. 


324 


DISEASES  OF  INFANTS  AND   CHILDREN. 


the  respirations  slow  and  irregular.  Death  usually  takes 
place  during  delivery  or  within  three  or  four  days  afterward. 
Cases  which  survive  show  monoplegia,  hemiplegia,  diplegia, 
or  mental  disturbance,  according  to  the  location  of  the  clot. 

Treatment. — The  judicious  use  of  forceps  to  hasten  slow 
labors  may  prevent  hemorrhage,  which  usually  is  caused  by 
the  long  pressure.  If  the  diagnosis  is  made,  a  very  skilful 
surgeon  might  operate  with  success. 

Spinal  Paralysis. — Very  rare.  Due  to  hemorrhage  or 
laceration,  and  results  in  paraplegia. 

Paralysis   of  the   Arm  in   the   Newborn  (ErVs 


Fig.  91.— Brachial  birth  palsy,  showing  limitation  of  motion. 

Paralysis). — This  is  from  injury  to  the  nerves  of  the  brachial 
plexus  during  parturition.  This  may  take  place  in  a  num- 
ber of  ways.  The  most  frequent  form  is  the  so-called 
Erb's  upper-arm  paralysis,  where  the  fifth  and  sixth  cervi- 
cal nerves  are  injured,  causing  paralysis,  partial  or  complete, 
of  the  biceps,  deltoid,  brachialis  anticus,  supinator  anticus, 
supinator  longus,  and  occasionally  of  the  supra-  and  infra- 
spinatus. Usually  noted  on  the  first  day  or  two,  but  it  may 
escape  notice  for  several  weeks.  The  upper  arm  is  paralyzed 
and  rotated  inward,  the  forearm  is  pronated  and  the  palm 
turned  outward.    The  triceps  and  the  muscles  of  the  forearm 


DISEASES   OF   THE  NERVOUS  SYSTEM. 


325 


and  hand  arc  unaffected.  Atrophy  occurs,  but  is  not  very 
noticeable  on  account  of  subcutaneous  fat.  Atrophy  is  more 
marked  in  older  children. 

More  rarely  the  paralysis  may  be  of  the  lower-arm  type, 
in  which  the  seventh  and  eighth  cervical  and  first  dorsal 
nerve  routes  are  involved,  or  there  may  be  a  combination  of 
the  upper-  and  lower-arm  types,  in  which  all  of  the  nerve 
routes  mentioned  above  are  injured 


Fig.  92.— Paralysis  of  right  facial  nerves. 

Diagnosis  by  the  group  of  muscles  affected.  Look  for  frac- 
tures of  the  clavicle,  separation  of  the  epiphysis,  and  disloca- 
tion of  the  humerus. 

Prognosis  varies.  If  recovery  takes  place  it  does  so  within 
three  months  ;  it  is  rare  after  that  time.  If  the  muscles  re- 
spond to  faradism  the  prognosis  is  good.  If  the  reaction  of 
degeneration  is  present  the  prognosis  is  bad. 


326  DISEASES  OF  INFANTS  AND   CHILDREN. 

Treatment  as  in  facial  paralysis.  Surgical  treatment,  con- 
sisting in  cutting  down  upon  the  brachial  plexus,  removing 
the  cicatrix,  and  approximating  the  ends  of  the  injured  nerves, 
has  been  tried  recently,  with  success  (see  Literature). 

Facial  Paralysis  of  the  Newborn. — This  is  usually, 
but  not  always,  from  the  pressure  of  forceps,  and  for  that 
reason  is  generally  unilateral.  Meningeal  hemorrhage  may 
also  be  a  cause. 

Symptoms  are  the  same  as  in  ordinary  facial  paralysis,  and 
are  noted  on  the  first  or  second  day. 

Exceptionally  facial  paralysis  may  be  due  to  congenital 
defect  of  the  nucleus  of  the  seventh  nerve.  Both  sides  may 
be  affected,  as  well  as  some  of  the  eye  muscles.  There  is  no 
treatment  for  this  form. 

The  prognosis  is  generally  good,  recovery  taking  place  in 
two  weeks,  though  in  some  the  paralysis  may  be  delayed 
months  or  be  permanent. 

Treatment. — None  the  first  three  weeks.  If  recovery  has 
not  taken  place,  use  faradic  electricity  daily.  If  muscles  do 
not  react  to  it,  use  galvanism. 

INFLAMMATION  OF  THE  BRAIN  AND  ITS  MEMBRANES. 

Pachymeningitis. — Inflammation  of  the  dura.  It 
may  be  acute  or  chronic. 

Acute  Pachymeningitis. — External. — Rare,  and  usually  fol- 
lows the  extension  of  suppuration,  as  in  middle-ear  disease. 

Internal. — As  a  part  of  inflammation  affecting  all  the 
membranes. 

Chronic  Pachymeningitis. — Internal. — This  is  seen  in 
cachectic  states  and  marantic  children.  There  is  usually 
hemorrhage. 

Symptoms. — Usually  not  marked  unless  there  is  hemor- 
rhage, which  may  cause  vomiting,  convulsions,  and  loss  of 
consciousness.  The  child  may  have  rigidity  of  the  muscles, 
enlarged  pupils,  and  paralysis,  according  to  the  location  of 
the  hemorrhage. 

Diagnosis. — Cases  without   hemorrhage   are   usually  only 


DISEASES  OE  THE  NERVOUS  SYSTEM. 


327 


discovered   at  autopsy.      From    acute  meningitis  by  lower 
temperature ;  coma  later,  and  rigidity  less  marked. 

Prognosis. — External  hemorrhages  are  usually  fatal ;  smaller 

ones  are  not. 

Treatment.— Ice  cap   to  head.      Bromids  and  chloral  to 

quiet  the  nervous  symptoms. 

Acute  Meningitis^ Cerebrospinal  Fever). — Definition. — 
An  acute  inflammation  of  the  pia  mater.  #  (See  also  Cere- 
brospinal Fever  and  Tuberculous  Meningitis.) 

Pathology.— The  inflammation  may  be  general,  involving 
the  entire  meninges,  both  cerebral  and  spinal,  or  it  may  be 
more  or  less  limited  to  an  area.  In  cerebrospinal  fever  it  is 
liable  to  be  general ;  in  tuberculosis  and  cachectic  conditions, 
chiefly  basal";  in  pneumonia  and  endocarditis,  chiefly  cortical; 
from  extension  of  middle-ear  disease  it  is  unilateral,  and  in- 
volves the  dura  more  extensively.  There  is  congestion,  and 
later  an  effusion  of  greater  or  less  intensity. 

Etiology. — Osier  gives  the  following  table  of  causes  : 


The  Etiology  of  Acute  Meningitis  (Osier). 


r  i. 

U 

L 


O     1 


Of   cerebrospinal 
fever 

Pneumococcic  .  . 
Tuberculous  .   . 


5  1 


1. 

2.  Pneumococcic  . 

3.  Pyogenic     .   .   . 


Miscellaneous 
acute  infections. 


(a)  bporadip.       1      Diplococcus  intracellulars. 
(6)  Epidemic.      J  y 

Meninges  alone  involved  or  ) 

in  a    general   pneumococ-  V  Pneumococcus. 

cic  infection.  ) 

Bacillus  tuberculosis 

(a)  Secondary  to  pneumonia,  1 

endocarditis,  etc. 

(b)  Secondary  to  disease  or 

injury  of  cranium  or  its 
fossae. 

(a)  Following  a  local  disease  1 

of    cranium  or  a  local 
infection  elsewhere.  Y 

(b)  Terminal  infection  in  va- 

rious chronic  maladies.  J 
In  typhoid  fever,  influ- 
enza, diphtheria,  gon- 
orrhea, anthrax,  ac- 
tinomycosis, and 
other  acute  diseases. 


Pneumococcus. 


Various  forms  of 
staphylococci 
and       strepto- 
cocci. 


Typhoid  bacillus,  in- 
fluenza bacillus, 
diphtheria  bacillus, 
gonococcus,  etc. 


Symptoms. — The  symptoms  are    also   given    under  Cere- 
brospinal Fever  and  Tuberculous  Meningitis. 

iCohoe  "  Influenzal  Meningitis,"  American  Journal  of  Medical  Sciences, 
January,  1909,  p.  75.  W.  T.  Councilman,  "  Meningitis,  Acute,"  Journal  of 
the  American  Medical  Association,  April  1,  1905,  p.  997. 


328  DISEASES  OE  INFANTS  AND   CHILDREN. 

Cortical  meningitis  may  not  produce  any  symptoms  which 
may  not  be  produced  by  congestion  or  by  the  toxemia  of  the 
specific  infections.  Basilar  meningitis  is  accompanied  by  re- 
traction of  the  head  and  symptoms  referable  to  the  cranial 
nerves.  There  may  be  ptosis  or  strabismus  ;  the  pupils  are 
at  first  contracted  ;  later,  dilated  or  unequal.  There  may  be 
twitching  or  facial  paralysis.  There  is  dread  of  light  (pho- 
tophobia) and,  later,  often  blindness.  There  is  a  dread  of 
noises  and,  later,  often  deafness.     Optic  neuritis  is  common. 

There  may  be  general  or  local  convulsions,  paralysis,  ten- 
derness of  the  skin  and  muscles  of  the  extremities.  There  is 
delirium,  and  frequently  profound  coma.  Vomiting  is  com- 
mon. Tache  cerebrale  is  common.  Kernig's  sign  is  present 
when  the  lower  spinal  meninges  are  involved.  Lumbar 
puncture  is  of  service.     (See  Cerebrospinal  Fever.) 

There  is  an  irregular  fever  curve. 

Diagnosis. — (See  Cerebrospinal  Fever  and  Tuberculous 
Meningitis.) 

Prognosis. — Bad.  All  cases  except  the  cerebrospinal  fever 
cases,  and  possibly  the  pneumococcus  cases,  die.  It  may  be- 
come chronic. 

Treatment. — The  disease  is  not  influenced  by  treatment. 
Open  the  bowels,  feed  carefully,  keep  quiet.  Ice  bag  to 
head.  Counterirritation  to  spine  and  nape  of  neck.  Salines 
if  there  is  much  congestion.  Lumbar  puncture  to  relieve 
brain-pressure  is  advisable.  Surgical  treatment  is  advisable 
in  localized  suppuration  and  meningo-encephalitis. 

Chronic  Basilar  Meningitis  in  Infants.1 

(Posterior  Basic   Meningitis.) 
Definition. — A   chronic  non-tuberculous    inflammation, 
especially  of  the  basal  meninges,  which  usually  occurs  spo- 
radically, but  which  may  be  seen  during  epidemics  of  cerebro- 
spinal fever. 

1  Still,  "  Posterior  Basic  Meningitis,"  Journal  of  Pathology  anal  Bacteri- 
ology, May,  1898,  p.  147.  O.  Hildesheim,  "  Meningitis,  Postbasic,  Prog- 
nosis in,"  British  Medical  Journal,  March  21,  1906,  p.  733.  H.  Koplik, 
"Meningitis,  Postbasic,"  American  Journal  of  the  Medical  Sciences,  February, 
1905,  p.  266. 


DISEASES   OF  THE  NERVOUS  SYSTEM.  329 

Etiology. — Usually  due  to  the  diplococcus  intracellularis. 
There  is  a  syphilitic  posterior  basic  meningitis  as  well. 

Pathology. — There  is  thickening  of  the  pia  and  dura 
mater  at  the  base  of  the  brain. 

Symptoms. — There  is  usually  a  gradual  onset,  followed 
by  retraction  of  the  head,  which  is  continuous,  opisthotonos 
and  muscular  rigidity.  In  some  instances  the  disease  may 
come  od  rather  suddenly,  with  vomiting,  fever,  convulsions 
and  rigidity.  The  child  may  be  partially  or  wholly  blind, 
often  without  any  optic  atrophy,  and  there  is  frequently  nys- 
tagmus or  strabismus.  There  may  be  hydrocephalus,  and  the 
fontanel,  if  open,  bulges.  The  position  assumed  is  that  of 
extreme  opisthotonos,  with  the  arms  drawn  in,  the  forearms, 
hands,  aud  fingers  flexed,  the  thighs  adducted,  the  legs  flexed, 
the  feet  extended,  and  the  toes  flexed.  There  is  extreme 
emaciation  and  the  abdomen  is  retracted.  The  temperature 
is  normal  or  but  slightly  elevated,  with  occasional  irregular 
periods  of  high  temperature. 

Diagnosis. — From  muscular  rigidity  of  marasmus  by 
the  greater  severity  of  the  opisthotonos,  the  hydrocephalus, 
and  the  cerebral  symptoms.  Lumbar  puncture,  is  of  value. 
A  dry  tap  may  result  in  these  cases. 

Prognosis.— -Usually  bad,  death  taking  place  in  from 
one  to  four  months.  Recovery  occasionally  occurs.  The 
older  the  child  the  better  the  prognosis.  Sudden  death  some< 
times  takes  place,  aud  the  disease  is  usually  followed  b\ 
paralysis  or  retarded  development,  and  occasionally  by  in- 
abilitv  to  gain  flesh,  by  the  persistence  of  headache 
and  subsequent  development  of  peculiarities  of  temper, 
morals,  or  emotions.  Amaurosis  and  optic  neuritis  have 
been  met  with,  but  both  are  rare.  The  same  is  true  of 
deaf-mutism. 

Treatment. — Iodid  of  potassium  and  mercurial  inunc- 
tions may  be  tried,  and  is  of  value  in  syphilitic  cases. 
Lumbar  puncture  may  be  done  to  relieve  pressure.  Flex- 
ner's  antimeningitis  serum  might  be  tried  in  the  cases  due  to 
ihe  meningococcus. 


330  DISEASES  OF  INFANTS  AND   CHILDREN. 


THROMBOSIS  OF  THE  SINUSES, 

Cachectic  Thrombosis. — Definition. — A  rare  condition 
where  the  blood  clots  in  the  sinus. 

Etiology. — It  is  seen  in  young  children  or  infants  wherever 
a  cachectic  condition  supervenes,  especially  in  the  course  of 
infections,  as  pneumonia,  whooping-cough,  and  diphtheria. 

Symptoms. — Usually  obscure ;  diagnosis  is  rarely  made 
during  life.     There  may  be  convulsions,  coma,  and  paralysis. 

Prognosis. — Fatal. 

Septic  Thrombosis ;  Inflammatory  Thrombosis ; 
Sinus  Phlebitis. — Definition. — A  clotting  of  the  blood  in 
the  sinus  from  meningitis  or  the  extension  of  an  inflamma- 
tion, as  from  otitis  or  pharyngitis. 

Symptoms. — In  meningitis  it  produces  no  new  symptoms. 
Headache,  localized  tenderness  of  the  scalp,  and  symptoms 
of  meningitis  are  present. 

Localized  Symptoms. — Superior  longitudinal  sinus  causes 
cyanosis  of  the  face,  nose-bleed,  dilatation  of  the  temporal 
veins.  Lateral  sinus  :  Dilatation  of  veins  and  edema  of  the 
mastoid  region.  The  clot  may  extend  into  the  jugular  vein. 
Cavernous  sinus  :  Protrusion  of  the  eyeball,  •  edema  of  the 
eyelid,  and  enlargement  of  the  retinal  veins. 

Prognosis. — Fatal  unless  operated  upon. 

Treatment. — Surgical. 

ABSCESS  OF  THE  BRAIN. 

Abscess  of  the  brain  may  be  single  or  multiple. 

etiology.- — Not  infrequent  in  early  life ;  secondary  to 
inflammations  of  the  ear  and  petrous  bone,  or  of  either 
cranial  bones.  It  may  follow  sinus  thrombosis.  It  may 
follow  injury. 

I/OCation. — Usually  in  frontal,  temperosphenoidal  lobes, 
or  cerebellum. 

Symptoms. — In  acute  cases  there  are  symptoms  suggest- 
ing meningitis,  as  headache,  painful  scalp,  vomiting,  fever, 
etc.     There  may  be  localized  symptoms  if  motor  areas  are 


DISEASES  OF  THE  NEBVOUS  SYSTEM.  331 

involved.  In  chronic  abscess,  which  may  last  a  long  while, 
attacks  of  headache,  fever,  or  vomiting  may  be  noted. 

Diagnosis. — Always  difficult.  Marked  rigors  and  very 
irregular  temperature  may  help  in  differentiating  tumors  or 
meningitis,  especially  when  the  symptoms  follow  ear  disease. 

Prognosis. — Always  bad. 

Treatment. — Surgical. 

CEREBRAL  TUMORS.1 

Starr's  table  gives  the  frequency  of  the  various  kinds  as 
follows:  Tubercle,  152;  glioma,  37;  sarcoma,  34;  gliosar- 
coma,  5;  cyst,  30;  carcinoma,  10;  gumma,  1;  not  stated, 
30  ;  total,  299. 

I/Ocation. — In  order  of  frequency  :  Cerebellum,  pons, 
centrum  ovale,  basal  and  lateral  ganglia,  corpora  quadri- 
gemina,  and  crura ;  the  other  locations  are  rare. 

Etiology. — Tuberculous  tumors  are  secondary ;  carci- 
noma and  sarcoma  may  be  primary  or  secondary.  Injury  is 
sometimes  stated  as  a  cause.  Boys  are  twice  as  frequently 
affected  as  girls,  and  most  cases  occur  before  eight  years  of  age. 

General  Symptoms. — Headache,  general  convulsions, 
changes  in  disposition  and  mental  activity,  double  optic  neu- 
ritis and  nerve  atrophy,  vomiting,  vertigo,  and  insomnia  are 
the  most  important  general  symptoms. 

I/OCal  Symptoms. — These  may  be  wanting,  or  may  be 
modified  by  size,  rapidity  of  growth,  or  by  meningitis. 

1.  Cortex  of  Cerebral  Hemispheres. — Optic  neuritis,  vom- 
iting, and  vertigo  are  infrequent. 

Frontal  Lobes. — Mental  deterioration,  sometimes  loss  of 
smell  on  affected  side  if  tumor  presses  on  olfactory  tract.  In 
the  third  frontal  of  the  left  hemisphere  of  right-handed  chil- 
dren (right  side  in  left-handed)  there  are  aphasia  and  agraphia. 

Central  and  Paracentral  Convulsions. — Paralysis  and  spasm 
of  limbs  on  opposite  side  of  body. 

Parietal  Lobe. — Xone,  or  disturbances  of  muscular  tem- 
perature and  pain-sense. 

Occipital    Lobe. — Hemianopsia,    psychic    blindness,    and 

1  Starr,  Keating' s  Cyclopedia,  1890. 


332  DISEASES  OF  INFANTS  AND   CHILDREN. 

word-blindness  (if  on  the  left  side)  in  right-handed  patients ; 
right  in  left-handed  children. 

Temper osphenoidal  Lobes. — Sensory  aphasia  or  word-deaf- 
ness if  in  left  first  or  second  convolution  ;  right  in  left-handed 
children. 

2.  Basal  Ganglia. — Marked  indirect  symptoms  from  pres- 
sure on  internal  capsule ;  optic  neuritis  occurs  early. 

3.  Corpora  Quadrigemina  and  Crura  Cerebri. — Rare.  Pupil- 
lary reflex  is  lost ;  there  are  nystagmus,  strabismus,  vertigo, 
and  ataxia.  Irregular  disturbances  of  sensation  of  face  and 
body.  If  large  the  tumor  causes  third-nerve  paralysis  on 
same  side  and  hemiplegia  on  opposite  side. 

4.  Pons  and  Medulla. — Symptoms  may  be  bilateral  on 
opposite  side  of  body ;  facial  and  other  cranial  nerve  paraly- 
sis on  same  side. 

5.  Cerebellum. — Vertigo,  cerebellar  ataxia,  headache,  and 
vomiting.  If  the  patient  falls  it  is  usually  in  same  direction. 
Hydrocephalus,  general  convulsions,  and  rolling  of  head  from 
side  to  side  may  occur. 

6.  Tumors  of  the  Base. — Symptoms  referable  to  the  cranial 
nerves  or  frontal  lobes  if  frontal,  basal  ganglia  and  crura  if 
middle  fossa,  pons  and  medulla  if  posterior  fossa. 

Diagnosis. — Variety.  Tubercle  most  frequent  and  of 
rapid  growth.     Gliosarcoma  is  of  slower  growth. 

From  Abscess. — Severe  rigors  and  leukocytosis  are  most 
important. 

Meningitis. — More  rapid  course  and  intense  symptoms.  In 
chronic  cases  symptoms  are  of  a  diffuse  lesion. 

Prognosis. — Always  bad. 

Treatment. — Surgical  if  tumor  is  accessible ;  antisyphi- 
litic  in  syphilis  and  palliative  in  other  cases. 

HYDROCEPHALUS. 

("Water  on  the  Brain.) 

Acute  Hydrocephalus. — A  collection  of  fluid  either 
beneath  the  dura  or  in  the  ventricles,  due  to  basilar  menin- 
gitis.    This    is    usually    tuberculous,    but    may    be    due    to 


DISEASES   OF  THE  XERVOUS  SYSTEM. 


333 


syphilis  or  to  other  diseases.  The  term  is  often  used  to  des- 
ignate tuberculous  meningitis. 

Chronic  Hydrocephalus. — External. — Very  rare. 
The  fluid  is  between  the  dura  and  the  pia.  Congenital  or 
due  to  pachymeningitis  or  subdural  hemorrhages.  Deform- 
ities of  the  brain  are  usually  present. 

The  brain  is  atrophied  or  deformed  and  pressed  against 
the  floor  of  the  skull.  General  appearance  and  symptoms  as 
in  the  internal  form.     The  two  forms  may  be  associated. 

Internal  or  Usual  Form. — Congenital  or  due  to  tumors  at 
the  base  of  the  brain  or  to  basilar  meningitis.     The  lateral 


Fig.  93.— Hydrocephalus. 

ventricles  are  distended  with  cerebrospinal  fluid.  The  brain 
substance  atrophies  and  the  convolutions  are  flattened.  The 
disease  usually  begins  early,  either  in  intra-uterine  life  or  soon 
after  delivery.  The  bones  of  the  skull  are  forced  apart,  the  su- 
tures are  very  wide,  and  the  fontanels  enormous.  Other  deform- 
ities, as  spina  bifida  and  harelip,  may  be  found  at  the  same  time. 
Hydrocephalus  may  occur  with  a  small  head,  due  to  premature 
ossification.  These  children  are  idiots  and  die  early,  often  during 
a  convulsion.    Such  cases  cannot  be  diagnosed  during  life. 


334  DISEASES  OF  INFANTS  AND  CHILDREN. 

Symptoms. — All  grades  of  symmetrical  enlargement  of  the 
head  are  met  with  ;  the  prominent  forehead  and  the  white  of 
the  eye  showing  between  the  cornea  and  the  upper  lid  give 
a  characteristic  expression.  The  head  may  fluctuate.  The 
skin  is  thinned  and  shiny  and  the  superficial  veins  dilated. 
The  enlargement  of  the  head  may  be  congenital;  it  may 
come  on  during  the  first  few  months  of  life  or  occasionally 
later.  These  children  are  idiotic,  lethargic,  often  blind  and 
deaf.     The  extremities  are  rigid  or  relaxed.     Nystagmus  and 

convergent  squint  are  com- 
mon. Convulsions  are  fre- 
quent. Occasionally  a  child 
may  have  a  moderate  grade 
of  hydrocephalus,  which  is 
gradually  recovered  from 
with  only  slight  mental 
impairment.  As  a  rule 
almost  all  die  during  t^.e 
first  year  and  the  remain- 
der before  seven  years  of 
age.  Now  and  then  a  pa- 
tient lives  longer. 

Treatment. — Unsatisfac- 
tory. All  sorts  of  meas- 
ures nave  been  tried.  As- 
piration gives  temporary 
relief,  but  the  fluid  soon 
accumulates.  Various  op- 
erative    procedures     have 


Fig.  94.— Hydrocephalus. 


been  tried,  such  as  permanent  drainage. 

INFANTILE  CEREBRAL  PARALYSIS.1 

(Spastic  Diplegia,  Paraplegia,  or  Hemiplegia.) 

Definition. — Paralysis  of  one  or  more  members  due  to 

disease  or  defects  of  the  brain  ;  either  congenital  or  acquired 

in  early  life. 

1  H.  W.  Noxon,  "  Paralysis,  Infantile,"  Practitioner,  November,  1906, 
p.  675. 


DISEASES   OF  THE  NERVOUS  SYSTEM. 


335 


Fig.  95.— Left  facial  paralysis  following  delivery  by  forceps  (BudinV 

Paralysis  of  Intra-uterine  Origin. — These  are  infrequent 
and  are  due  to  arrested  development,  hemorrhage,  or  other 
lesions.    There  may  be  large  or  small  cysts  or  defects  (poren- 


FlO.  96  — Showing  contraction  in  infantile  cerebral  paralysis. 


336 


DISEASES  OF  INFANTS  AND   CHILDREN. 


cephalv)  in  any  part  of  the  brain.     There  may  be  cortical 
agenesia — i.  e.,  want  of  development  of  the  cortical  cells. 

Birth  Paralysis. — These  are  due  to  hemorrhage  (see  page 
323).  If  the  child  lives  there  may  be  meningoencephalitis, 
cysts,  atrophy  and  sclerosis  of  the  cortex,  or  secondary  de- 
generation of  the  cord. 

Cerebral  Paralysis. — This  is  usually  a  hemiplegia ;  but 
other  forms  may  be  met  with.  It  may  follow  injury,  infec- 
tious diseases,  or  from  a  convul- 
sion or  paroxysm  of  coughing,  as 
in  pertussis.  The  lesions  found 
may  be  hemorrhage,  meningitis, 
or  atrophy  or  sclerosis  of  the  cor- 
tex, with  secondary  degenerations. 


Fig.  97.— Right  hemiplegia  following  men- 
ingeal hemorrhage. 


Fig.  98.— Infantile  cerebral  paraly- 
sis (Gillette). 


Symptoms. — Paralysis  dating  from  birth  is  usually 
either  diplegia  or  paraplegia  ;  but  hemiplegia  may  be  met 
with.  The  degree  of  paralysis  and  its  extent  depend  on  the 
lesion.  There  is  usually  a  spastic  condition  of  the  muscles 
with  increased  tendon  reflexes,  but  the  paralysis  may  be  of 
the  flaccid  type.     Athetoid  movements  are  common.    Speech 


DISEASES  OE  THE  NERVOUS  SYSTEM.  337 

disturbances  may  be  met  with,  and  there  is  nearly  always 
mental  impairment,  often  idiocy. 

Symptoms  of  Acquired  Paralysis. — Sudden-  onset,  generally 
with  a  convulsion,  fever,  and  loss  of  power.  The  paralysis  is 
usually  a  hemiplegia.  There  may  be  speech  disturbances. 
Later  there  is  lack  of  development  and  contractures.  The 
mental  condition  is,  as  a  rule,  unimpaired.  Sometimes  there 
may  be  athetoid  movements. 

Diagnosis. — It  may  be  impossible  to  tell  the  acquired 
from  the  congenital  forms  except  by  the  history ;  from  spinal 
paralysis  by  the  wide  extent,  diplegia,  paraplegia,  or  hemi- 
plegia, by  the  spasticity  of  the  muscles,,  increased  reflexes, 
contractures,  and  absence  of  reaction  of  degeneration.  Often 
mistaken  for  rickets. 

Treatment. — Training  of  the  muscles  remaining.  If 
there  are  deformities  and  contractures,  orthopedic  appliances 
and  operations  may  be  advisable. 

MYASTHENIA  GRAVIS.1 
(Erb-Goldflam  Syndrome;  Asthenic  Bulbar  Paralysis*) 

A  disease  usually  beginning  in  early  life  and  characterized 
by  a  marked  loss  of  power  on  exertion  of  certain  muscles, 
which  is  recovered  from  after  rest.  The  muscles  supplied  by 
the  nerves  emanating  from  the  medulla  (bulb)  are  first  affected. 
Paralysis  and  atrophy  may  follow7.  There  is  a  curious  myas- 
thenic reaction  (Jolly),  the  muscles  rapidly  tiring  on  application 
of  the  faradic  current,  but  not  from  the  galvanic.  About  one- 
third  of  the  cases  die;  some  persist  for  years  and  some  recover. 

Treatment. — Mercury  and  iodide  rest,  strychnin,  and 
massage. 

IDIOCY;  FEEBLE-MINDEDNESS ;  IMBECILITY.2 

Idiocy  is  mental  deficiency  depending  upon  malformations, 
arrested  developments,  or  lesions  acquired  before  the  mental 

1  Campbell  and  Bramwell,  Brain,  1901. 

2  Ireland,  Mental  Diseases  of  Children.  Lepage,  "  Diagnosis  of  Perma- 
nent Mental  Deficiency  in  Infancy  and  Childhood,"  Practitioner,  August, 
1909,  p.  211. 

22 


338  DISEASES  OF  INFANTS  AND  CHILDREN. 

faculties  have  developed.  Imbecility  is  a  term  applied  to 
mild  grades  of  idiocy  which  are  not  severe  enough  to  war- 
rant the  confinement  of  the  individual  in  an  institution. 

Various  classifications  of  idiots  are  used.  The  following 
is  a  modification  of  Ireland's  classification  : 

1.  G-enetotis  Idiocy. — This  form  is  caused  by  malfor- 
mations of  the  brain. 


Fig.  99.— Genetous  idiot. 

2.  Microcephalic  idiocy  is  associated  with  a  very 
small  head  ;  frequently  there  is  premature  ossification  of  the 
bones  of  the  skull.  The  fontanels  close  early  or  may  be 
closed  at  birth.  The  head  is  pointed,  the  forehead  receding, 
and  the  occiput  flat. 

3.  Hydrocephalic  idiocy,  where  the  lesion  is  hydro- 
cephalus. 


DISEASES  OF  THE  SERVO  US  SYSTEM. 


339 


4.  Epileptic  idiocy,  where  the  idiot  is  an  epileptic. 

5.  Paralytic  idiocy,  in  which  there  are  associated  pa- 
ralyses such  as  described  under  Cerebral  Paralysis. 

6.  Inflammatory  idiocy,  following  inflammatory 
changes,   usually  the  result  of  meningitis. 

7.  Idiocy  by  deprivation,  where  the  brain  is  appa- 
rently normal,  but  owing  to  blindness  or  deafness  and  want 
of  instruction  the  child  remains  an  idiot. 


Fig.  100.— Congenital  idiot  of  low  grade 
(Mills). 


Fig.  101.— Epileptic  imbecile  (Mills). 


8.  Mongolian  idiocy  comprises  aoout  5  per  cent,  of  all 
idiots,  and  in  it  there  are  physical  characteristics  suggesting 
the  Mongolian  race,  associated  with  mental  and  physical  de- 
ficiency. They  are  usually  born  of  older  mothers,  the  aver- 
age age  being  thirty-eight  (Thomson).  The  head  is  short, 
small,  and  round,  and  the  eyes  have  a  decided  slant,  the  outer 
canthus  being  higher  than  the   inner,  and  there  is  often  an 


340 


DISEASES  OF  INFANTS   AND   CHILDREN, 


epicanthic  fold  at  the  inner  canthus.  There  is  often  blepha- 
ritis. Adenoids  are  common,  causing  month  breathing,  and 
the  tongue  is  usually  large  and  protruded.  The  teeth  are 
small  and  decay  early,  and  the  incisors  may  be  set  at  an  angle. 
The  ears  often  lack  the  normal  state  and  are  smooth.  The 
extremities  are  small,  relaxed,  and  soft.  The  little  finger 
has  a  curve.     Congenital   heart   lesions  are  common.     De- 


Fig.  102.— Insane  imbecile 
(Mills). 


Fig.  103.— Congenital  idiot  of  low- 
grade  (Mills). 


velopment  is  slow  and  they  may  not  walk  for  several  years. 
They  learn  to  talk  slowly  and  with  difficulty.  They  are 
usually  bright,  mischievous,  and  learn  to  do  a  few  tricks  by 
imitation.  The  outlook  is  unencouraging,  for  while  they 
may  conduct  themselves  with  fair  propriety,  they  never  be- 
come self-supporting. 

9.  Cretinism. ^-(See  below.) 


DISEASES  OF  THE  NERVOUS  SYSTEM.  341 


Fig.  104  —Mongolian  idiot. 


Fig.  105.— Mongolian  idiot. 


10.  Amaurotic   Family  Idiocy.1— This   is   a   pecu- 

1  Sachs,  New  York  Medical  Journal,  May  30,  1896. 


342 


DISEASES  OF  INFANTS  AND   CHILDREN. 


liar  disease  of  unknown  origin  seen  in  Hebrew  children, 
several  cases  often  occurring  in  one  family.  It  begins 
usually  between  the  third  and  sixth  month,  and  the  men- 


Fig.  106.— Amaurotic  family  idiocy,,  showing  facial  expression. 

tal  condition  becomes  that  of  a  hopeless  idiot.  There  is 
a  vacant  idiotic  expression.  The  most  characteristic  thing 
is  blindness,  associated  with  optic  atrophy  and  a  red  spot  ®n 
the  center  of  a  red  spot  in  the  center  of  a  bluish- white  disk 


Fig.  107.— Amaurotic  family  idiocy,  showing  flaccid  condition  of  the  muscles. 

on  the  site  of  the  macula  lutea.  There"  is  a  relaxed,  flaccid 
condition  of  the  muscles  of  the  entire  body,  occasionally 
spasticity,  the  reflexes  are  usually  absent,  but  may  be  in- 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


343 


creased.  The  child  passes  into  a  condition  of  malnutrition, 
and  usually  dies  within  a  year. 

The  diagnosis  is  confirmed  by  ophthalmic  examination. 

The  prognosis  is  hopeless,  and  there  is  no  treatment  known 
that  influences  the  disease. 

Diagnosis. — As  a  rule  the  exact  grade  of  mentality  can- 
not be  estimated  in  a  young  infant,  but  mental  deficiency 
may  often  be  determined  early  by  the  presence  of  some 
marked  physical  accompaniment,  as  microcephalics,  hydro- 
cephalus, or  spastic   diplegia,  and  of  recent  years  a  great 


Fig.  108.— Amaurotic  family  idiocy,  showing  extreme  relaxation. 

deal  has  been  written  about  the  stigmata  of  degeneration 
(see  same),  or  minor  physical  malformations  which  may  be 
seen  in  otherwise  normal  children,  but  which  in  accordance 
with  Warner's  law  of  coincident  development  ("when  any 
part  or  parts  of  the  body  present  signs  of  defective  develop- 
ment the  brain  is  very  apt  to  be  defective  likewise ")  are 
most  frequent  in  the  mentally  deficient.  Convulsions  are 
frequent  in  idiots  and  imbeciles,  and  of  considerable  import- 
ance are  the  numerous  abnormal  gestures  and  actions,  head 
rolling,  and  the  like.     There  is  sometimes  constant  crying 


341 


DISEASES  OE  INFANTS  AND   CHILDREN. 


for  no  apparent  cause,  grimacing,  or  senseless  laughter.  The 
child  cannot  fix  its  attention,  or  only  for  very  short  periods. 
The  development  mentally,  physically,  and  morally  is  always 
slow  and  irregular,  even  in  the  milder  cases. 

In  estimating  a  child's  mental  condition  it  is  important  to 
bear  in  mind  the  effect  of  physical  defects  on  its  education, 
such  as  blindess,  deafness,  and 
other  physical  defects,  also  of 
the  effect  of  serious,  prolonged 
illnesses,  and  of  the  child's  pre- 
vious environment. 

Prognosis. — Many  of  the 


Fig.  109.— Idiot.    Flaccid  type. 


Fig.  110.— Idiot.    Spastic  diplegia. 


mentally  deficient  die  early,  and  the  remainder  may  be  divided 
into  the  hopeless  cases  and  those  who  can  be  benefited  by 


training. 


Treatment. — The  child's   physical    welfare    should   be 
cared  for,  suitable  food,  warm  clothing  in  cold  weather,  baths, 


DISK.  JES  OF  THE  NERVOUS  SYSTEM. 


345 


and  out-of-door  life  are  all  important.  Adenoids  should  be 
removed,  if  present,  and  all  physical  ailments  treated.  Epi- 
leptics and  cretins  need  especial  treatment.  Surgical  opera- 
tions on  the  bead  are  of  no  value.  Training  of  mind  and 
body  should  be  begun  as  early  as  possible,  and  various  physi- 
cal exercises  carried  out  daily  ;  all  sorts  of  games  and  drills 
may  be  utilized.  The  child  must  be  taught  to  chew  his 
food,  to  wash  and  dress  himself.  Arouse  his  interest,  if  pos- 
sible,   by   music,    lights,    pictures,  and   objects.     Encourage 


Fig.  111.— Idiot.    Flaccid  type. 


him  to  play  with  things  and  to  do  things  for  himself.  The 
acquisition  of  undesirable  traits  and  habits,  such  as  grimac- 
ing and  making  various  movements  and  noises,  should  be 
discouraged.  Self-control  should  be  inculcated.  In  most 
instances  these  children  do  better  in  institutions  of  the  right 
sort  than  at  home.     (See  pamphlet,  page  528.) 

High-grade  Imbeciles  and  the  Morally  Deficient. 
— These  represent  a  very  difficult  class  to  deal  with,  as  the 


346  DISEASES  OF  INFANTS  AND   CHILDREN. 

diagnosis  and  prognosis  are  difficult  and  uncertain.  These 
children  comprise  those  from  the  beginning  of  the  school  age 
up  to  puberty,  and  are  represented  by  those  children  who  are 
nearly  normal,  both  physically  and  mentally,  but  who  are 
slow  in  acquiring  the  difference  between  right  and  wrong, 
aud  who  exceed  the  extreme  limit  that  might  reasonably  be 
allowed  for  childish  pranks  and  juvenile  irresponsibility,  and 
who  persistently  and  repeatedly  do  so.  Stealing,  arson,  de- 
struction of  property,  masturbation,  uncontrollable  fits  of 
temper  are  the  more  troublesome  features.  Sometimes  the 
condition  may  be  ascribed  to  previous  environment  or  lack 
of  control,  and  may  be  entirely  overcome  by  proper  training 
and  development,  but  in  my  experience  the  majority  of  these 
cases  represent  high-grade  imbeciles  with  a  gloomy  prognosis. 
Treatment. — The  child  should  be  removed  from  its 
accustomed  environment  and  placed  in  a  good  strict  school. 
If  possible,  they  should  never  be  sent  to  institutions  for  the 
feeble-minded  nor  to  penal  institutions,  as  is  often  done. 

CRETINISM.1 
(Infantile  of  Juvenile  Myxedema.) 

Definition. — A  chronic  disease  characterized  by  a  re- 
tardation in  development,  both  physical  and  mental,  a  curious 
edema-like  condition  of  the  subcutaneous  tissue,  and  absence 
of  disease  of  the  thyroid  gland.  Cretinism  may  be  endemic 
or  sporadic.  The  sporadic  form  may  be  congenital  or  ac- 
quired. 

Etiology. — The  endemic  form  is  s£en  in  certain  moun- 
tainous countries,  in  dwarfs  with  short  bodies,  legs,  and  arms, 
a  low  grade  of  mentality,  a  myxedematous  condition  of  the 
subcutaneous  tissue,  and  many  of  them  have  a  goiter. 

The  sporadic  form  is  found  all  over  the  world.  The  cause 
is  unknown.  The  lesion  or  absence  of  the  thyroid  seems  to 
be  responsible  for  the  retardation  and  myxedema.  The  ac- 
quired form  may  come  on  after  the  acute  infections  in  which 
changes  in  the  thyroid  have  taken  place.  It  may  follow 
removal  of  the  thyroid  by  operation. 

1  Osier,  American  Journal  Medical  Sciences,  1897. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


347 


Pathology. — Absence,  degeneration,  or  atrophy  of  the 
thyroid,  or  in  some  cases  goiter,  together  with  slow  ossifica- 
tion and  growth  of  the  bones,  and  deposits  in  the  sub- 
cutaneous tissue  giving  the  reactions  of  mucin. 

Symptoms. — These  may  come  on  at  any  time,  but  are 
usually  not  noticed  until  the  second  year. 

In  Early  Infancy. — Sluggishness,  torpor,  low  temperature, 
and  cretin  expression,  puffy  eyelids,  open  mouth,  and  pro- 


Fig.  112.— Sporadic  cretin  :  before  treatment.     (From  Osier,  Sporadic  Cretinism  in 

America.) 

truding   tongue.      There    is    hoarseness.      The    abdomen  is 
prominent. 

Later  Symptoms. — In  well-developed  cretins  the  appear- 
ance is  characteristic.  The  arms  and  legs  are  short ;  body 
seems  too  large  and  head  much  too  large  for  the  extremities. 
The  fontanel  is  open  for  years.  The  expression  is  pig-like. 
The  eyes  are  wide  apart  and  the  palpebral  fissure  is  narrow. 
The  eyebrows  are  scanty  or  wanting ;  the  cheeks  are 
prominent.     The  lips  are  thick,  the  mouth  open,  the  tongue 


348 


DISEASES  OF  TNFANTS  AND   CHILDREN, 


large  and  protruding.  There  is  drooling  of  the  saliva. 
Dentition  is  delayed.  The  body  and  extremities  are  mis- 
shapen and  laek  the  grace  and  proportion  of  normal  infants. 
The  hands  are  thick  and  broad ;  the  abdomen  prominent, 
the  genitalia  undeveloped.  The  skin  is  rough  and  there  is 
an  edematous  condition  which  does  not  pit  on  pressure.  Sub- 
cutaneous lipomata  are  common.  The  voice  is  hoarse.  Some 
cretins  are  deaf  and  dumb.  Constipation  is  present.  Walk- 
ing is  begun  late.     A  cretin  of  twenty  may  resemble  a  child 


Fig.  113.— Sporadic  cretin  :  after  treatment.     (From  Osier.  Sporadic  Cretinism  in 

America.) 

of  a  few  years  of  age,  both  in  stature  and  mentality.  The 
mental  condition  of  cretins  is  one  of  apathy  and  little  or  no 
development. 

Partially  developed  cases  of  cretinism  (myxedeme  fruste) 
are  sometimes  seen.  They  show  the  symptoms  partially 
developed. 

Diagnosis. — Late   dentition,    open    fontanel    after   two 


DISEASES   OF   THE  NERVOUS  SYSTEM,  349 

year-,  with  mental  inactivity, and  the  changes  described  above 
make  the  diagnosis  easy. 

Differential  Diagnosis. — Mongolian  Idiocy. — The  Mon- 
golian type  of  face,  brighter  mentality,  and  no  myxedema. 

Infantilism. — (See  sam< 

Achondroplasia. — I  See  same.) 

Prognosis. — If  untreated,  hopeless.  They  remain  idiots 
and  usually  die  before  thirty  from  some  other  disease. 
Treated  early,  the  outlook  is  most  promising  for  full  recovery  ; 
treated  late,  the  results  are  not  satisfactory. 

Treatment. — The  iuterual  administration  of  tablets  of 
the  thyroid  gland.  Small  doses  increased  gradually  to  5 
grams  three  or  four  rime.-  a  day,  or  even  larger  doses.  Too 
much  causes  rapid  pulse,  flushing,  and  fever.  Changes 
begin  to  take  place  in  a  month  or  six  weeks.  The  child 
becomes  natural  in  appearance  and  develops  mentally  and 
physically.  After  the  normal  appearance  and  development 
is  reached,  reduce  treatment  to  two  5-grain  tablets  a  week. 
This  must  be  continued.  If  it  is  stopped,  symptom-  of 
cretinism  return  in  a  month  or  six  weeks.  Small  portions 
of  thyroids  are  sometimes  grafted  into  cretin-. 

INFANTILISM.1 

A  condition  in  which  the  appearance  of  infancy  or  child- 
hood is  preserved  in  the  adult.  Sexual  development  is 
backward,  absent,  or  perverse.  Lamy  gives  the  following 
description  :  "  The  face  is  rounded  and  chubby;  the  lips 
prominent  and  plump,  the  nose  poorly  developed,  the  face 
smooth,  the  skin  fine  and  of  a  clean  color,  the  hair  fine,  the 
eyebrows  and  lashes  sparse,  the  trunk  long  and  cylindrical. 
The  abdomen  is  somewhat  prominent,  the  arms  and  legs 
plump  and  tapering  from  the  trunk  to  the  extremity.  A 
layer  of  adipose  tissue  surrounds  the  body  and  marks  the 
bony  and  muscular  prominences.  The  genital  organs  are 
rudimentary.  There  is  an  absence  of  hair  on  the  pubes  and 
axilla?.     The  voice  is    shrill    and   piercing.     The  larynx  is 

1  W.  B.  Eausom.  "  InJantilism,"  Practitioner,  September,  1906,  p.  339. 


350  DISEASES  OF  INFANTS  AND   CHILDREN. 

poorly  developed  and  the  thyroid  small."     These  cases  may 
be  mistaken  for  cretinism  by  careless  observers. 

ACHONDROPLASIA.1 

(Fetal  Rickets;  Fetal  Myxedema.) 

A  curious  form   of  dwarfism,  usually  congenital,  but  ex- 
ceptionally appearing  a  few  years  after  birth.     Most  cases 


Fig.  114.— Achondroplasia  (case  of  Fig.  115.— Achondroplasia  :  Skeleton. 

Dr.  West  and  Piper,  courtesy  of  the 
Archives  of  Pediatrics) . 

are  born  dead  or  die  soon  after  birth,  but  some  live  to  old 
age.  They  have  large  heads,  very  short  arms  and  legs.  The 
humerus  and  femur  are  liable  to  be  very  short.     The  trunk 

1  Bankin  and  Mackay,  "  Achondroplasia,"  British  Medical  Journal,  June 
30,  1906,  p.  1518.  C.  Herrman,  "  Achondroplasia,  Mongolism,  and  Cretin- 
ism, Diagnosis  of,"  Archives  of  Pediatrics,  1905,  p.  493.  Thomson,  ' '  Achon- 
droplasia, Clinical  Features,"  Edinburgh  Medical  Journal,  June,  1893. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


351 


is  small  and  normal.  The  epiphyses  of  the  long  bones  are 
enlarged,  the  shafts  normal.  The  hands  are  short  and  spade- 
like  and  the  fingers  deviate  ("Trident  Hand").  The  intel- 
lect is  about  that  of  a  child  of  the  same  size ;  occasionally 
the  intellect  is  fair.  They  are  mischievous  and,  unlike  most 
dwarfs,  have  strong  sexual  instincts. 

DWARFISM, 

This  may  be  due  to  a  variety  of  causes,  among  them  cre- 
tinism, infantilism,  mongolism,  achondroplasia,  and  rickets 
(see  same).     It  may  also  be   due   to   prolonged  periods  of 


Fig.  116. — Achondroplasia  :  Trident  hand. 

underfeeding,  especially  when  combined  with  bad  hygienic 
surroundings.  Prolonged  stomach  or  intestinal  disease, 
syphilis,  severe  disease  of  liver  or  pancreas,  chronic  heart  or 
lung  disease,  and  certain  forms  of  congenital  brain  defects 
may  also  at  times  cause  dwarfing.  There  is  no  specific  treat- 
ment except  in  the  case  of  cretinism,  but  thyroid  extract 
may  be  cautiously  tried  in  all  forms  of  dwarfing,  as  occasion- 
ally a  defective  thyroid  may  cause  slow  growth  and  little 
else.  Syphilis  should  be  treated  if  it  exists,  and  other  dis- 
orders relieved  if  possible. 


352  DISEASES  OF  INFANTS  AND   CHILDREN. 

CLEIDOCRANIAL  DYSTOSIS.1 

This  is  a  rare  congenital  condition  in  which  there  is  an 
enlarged  cranium  and  small  face  bones,  a  late  closing  fontanel, 
and  an  entire  or  partial  absence  of  the  clavicles,  so  that  the. 
shoulders  may  be  brought  together  in  front  of  the  body. 
There  may  be  other  defects  of  the  bones.  The  soft  parts  are 
normal  and  the  mental  condition  usually  good.  The  disease 
most  often  occurs  in  families.     There  is  no  treatment. 

INSANITY, 

Comparatively  little  is  known  concerning  the  psychoses 
of  infancy  and  childhood.  In  insanity  the  mind  has  been 
previously  sound.  Insanity  is  rare  in  childhood.  The  same 
forms  are  met  with  as  in  adults,  mania  being  the  most  fre- 
quent. Epileptic  children  often  show  symptoms  of  mental 
disease,  and  the  same  is  true  of  defective  children. 

Etiology. — Infectious  diseases,  neurotic  taint,  reflex 
disturbances,  and  mental  strains  are  the  most  frequent 
causes. 

Symptoms. — These  are  somewhat  similar  to  the  adult 
form  of  mental  diseases. 

Prognosis. — Good  in  acute  cases  with  proper  treatment. 
Where  the  insanity  is  hereditary  the  prognosis  is  bad. 

Treatment. — As  in  adults. 

DEVELOPMENTAL  OR  JUVENILE  GENERAL  PARALYSIS.2 
This  is  a  mental  deterioration  resembling  closely  the 
general  paresis  of  adults.  It  is  usually  syphilitic  in  charac- 
ter. It  usually  comes  on  in  children  who  have  previously 
shown  some  mental  defects.  Once  started,  the  course  is 
progressive.  The  symptoms  vary  considerably,  but  in 
younger  children  there  is  usually  spastic  diplegia  and  often 
convulsions.  There  may  be  optic  atrophy,  the  pupils  may 
be  unequal,  and  there  may  be  an  Argyll-Robertson  pupil. 
There  may  be  a  tremor.     The  speech  is  affected  as  in  adults. 

1  Schorstein,  Lancet,  January,  1899,  p.  10,  and  G.  Carpenter,  Ibid.,  p.  13. 

2  Thomson  and  Welch,  British  Medical  Journal,  April  1,  1899. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


353 


The  knee-jerks  may  be  exaggerated  and  later  lost.  The 
plantar  reflex  may  be  extension.  The  disease  lasts  several 
years  and  terminates  fatally. 

No  treatment  known  has  any  effect. 

STIGMATA  OF  DEGENERATION* 

Stigmata  of  degeneration  are  signs  of  physical,  mental,  or 
moral  degeneracy,  and  are  to  be  regarded   as   indicating  a 


Fig.  117.— Dental  irregularities  in  idiocy  and  degeneration  (Talbot,  GaiUard's  Medical 

Journal.  1902). 

nenropathic  taint.  Some  of  the  following  are  always  to  be 
regarded  as  signs  of  degeneracy,  others  only  when  associated. 
They  are  divided  into  anatomic,  physiologic,  and  psychic. 

Anatomic. — Facial  asymmetry,  very  high  arched  or 
other  deformities  of  the  palate,  pigmentary  retinitis,  and  de- 
formities of  the  ear  and  genitalia  are  among  the  more  im- 
portant ones.      Anomalies  or  malformations  of  any  of  the 


354  DISEASES  OF  INFANTS  AND   CHILDREN. 

organs,  infantilism,  gigantism,  and  dwarfism  are  also  to  be 
regarded. 

Physiologic. — Hysteria,  epilepsy,  tics,  tremors,  mi- 
graine, hyperesthesia,  color-blindness,  and  speech  disturb- 
ances are  the  most  important.  Anomalies  of  the  function  of 
any  organ  may  also  be  considered. 

Psychic. — Imbecility,  idiocy,  insanity,  moral  delin- 
quency, and  sexual  perversion  are  the  most  important. 

DEAF-MUTISM.1 

This  may  be  congenital  or  acquired.  The  acquired  form 
follows  scarlet  fever,  cerebrospinal  fever,  or  other  infectious 
diseases,  or  it  may  be  due  to  otitis  from  other  causes. 

Treatment. — Educating  what  little  hearing  remains  and 
teaching  the  child  to  talk.  This  is  best  commenced  at  three 
years  of  age,  and  the  child  should  be  in  an  institution. 

1  Drummond,  "  The  Early  Care  of  the  Deaf  and  Dumb,"  Pediatrics, 
December  15,  1901,  p.  440. 


DISEASES  OF  THE  SPINAL  CORD. 


355 


DISEASES  OF  THE  SPINAL  CORD. 
MALFORMATIONS. 
Spina  bifida  is  the  most  important.     The  most  frequent 
form  is  mmingvmydocde  (fluid  in  the  meningeal  sac)  of  the 


F'j ■..  118.— Spina  bifida. 


Fig.  119.— Spina  bifida. 


sacrolumbal'   region.      Meningocele    or    syringomyelocele  (the 
fluid  is  accumulated  in  the  central  canal  of  the  cord)  may 


350  DISEASES  OF  INFANTS  AND   CHILDREN. 

fluid  is  accumulated  in  the  central  canal  of  the  cord)  may 
also  be  occasionally  seen.  Other  malformations  may  be 
present.  The  tumor  is  present  at  birth  and  tends  to  increase 
in  size.  Rupture  may  take  place,  and  death  result  from 
infection   or  secondary  infection. 

Prognosis. — Meningocele  covered  by  skin  may  be  cured. 
In  meningo-encephalocele  the  prognosis  is  bad,  especially  if 
there  is  paralysis,  and  hopeless  if  there  is  hydrocephalus. 
Syringomyelocele  is  hopeless. 

Diagnosis. — Meningocele  gives  usually  a  pedunculated 
translucent  tumor ;  meningomyelocele,  a  sessile  tumor  hav- 
ing a  central  scar  or  urabilication,  is  frequently  associated 
with  paraplegia,  and  a  fissure  can  be  felt  in  the  spine ;  syrin- 
gomyelocele is  usually  associated  with  hydrocephalus. 

Treatment. — Protect  from  rupture.  Operations  should  be 
done  if  there  is  no  paralysis  or  hydrocephalus  or  severe  as- 
sociated conditions. 

SPINAL  MENINGITIS. 

Definition. — Inflammation  of  the  spinal  meninges. 

Etiology. — Most  frequently  associated  with  cerebral 
meningitis,  or  myelitis,  occasionally  traumatic.  External 
pachymeningitis  follows  spinal  caries. 

Symptoms. — These  are  due  to  pressure  on  the  nerve 
roots  or  cord  itself.  The  most  marked  are  rigidity  of  spine 
and  muscles  of  extremities,  pain  in  the  course  of  the  nerves 
pressed  upon,  tenderness  over  the  spine,  and  from  cord-pres- 
sure, paralysis,  atrophy,  and  anesthesia. 

Diagnosis. — Irritative  symptoms  point  to  meningitis, 
marked  paralysis  and  anesthesia  to  myelitis. 

Treatment. — Rest,  immobilization  of  spine,  counter- 
irritation  ;    internally,  iodid  of  potassium. 

MYELITIS. 

Definition. — An  inflammation  of  the  spinal  cord. 

Ktiology. — In  children  it  is  usually  either  acute  polio- 
myelitis or  compression  myelitis.  Acute  myelitis  may  be 
traumatic  or  follow  the  infectious  diseases.  Chronic  myelitis 
is  seen  in  hereditary  syphilis. 


DISEASES  OF  TJTF.   SPINAL   conn.  357 

Symptoms. — Acute  poliomyelitis  and  compression-mye- 
litis are  given  below.     Symptom-  depend  upon  the  location 

of  the  lesion.  There  are  "girdle  pains"  at  the  level  of  the 
lesion  and  loss  of  reflexes.  Below  the  lesion  the  reflexes 
are  inereased.  There  may  be  loss  of  control  of  bladder  and 
rectum,  contracture  or  flaccidity  of  the  muscles,  reaction  of 
degeneration,  and  bed-sores.  Localizing  symptoms  are  exactly 
the  same  as  in  adults. 

Prognosis. — Bad.  The  course  is  chronic  and  progres- 
sive;  death  usually  results  from  intercurrent  disease. 

Treatment. — Rest;  counterirritation.  Iodid  of  potas- 
sium should  be  given  in  large  doses  after  the  acute  stage  is 

CO  o 

passed. 

COMPRESSION  MYELITIS, 

(Pott's  Paraplegia;  Pressure  Paralysis  of  the  Cord.) 

Definition, — Myelitis  due  to  pressure  on  the  spinal  cord. 

Etiology. — Nearly  always  from  tuberculous  caries  of  the 
spine ;  exceptionally  from  tumor  or  aneurism.  It  may  fol- 
low injury. 

Pathology. — The  cord  is  usually  compressed  in  the 
angle  of  the  spine  caused  by  the  caries,  or  from  inflammatory 
products  between  the  cord  and  spine,  or  both  together.  The 
cord  becomes  inflamed  and  degeneration  may  take  place. 

Symptoms. — Spastic  paralysis  and  increased  reflexes  of 
slow  onset  usually  affecting  the  legs  only  ;  in  cervical  caries, 
legs  and  arms.  Radiating  pains  and  other  symptoms,  as  in 
myelitis,  are  present. 

Diagnosis. — From  other  forms  of  myelitis,  by  the  pres- 
ence of  deformity,  where  this  does  not  exist  by  absence  of 
other  causes  of  myelitis,  tenderness  over  the  spinal  processes, 
and  pain  with  the  paralysis  are  of  value. 

Prognosis. — This  depends  largely  on  the  course  of  the 
original  bone  disease.  Cervical  cases  are  more  serious  than 
lower  ones.  The  motor  symptoms,  as  a  rule,  persist  longer 
than  the  sensory  ones. 

Treatment. — This  is  surgical,  usually  by  orthopedic 
appliances,  plaster  casts  and  the  like. 


358 


DISEASES  OF  INFANTS  AND   CHILDREN 


TUMORS  OF  THE   SPINAL  CORD. 
These  are  very  rare  in  childhood  and  present  the  same 
symptoms  as  in  adults.      They  may  be  mistaken  for  Pott's 

disease.     The  diagnosis  is  not  made 


in  infants  during  life. 


SYRINGOMYELIA. 

This  is  occasionally  seen  in  early 
life.  There  is  dilatation  of  the  central 
canal  of  the  spinal  cord,  with  or  with- 
out the  pressure  of  glioma.  There  is 
progressive  paralysis  with  atrophy. 
Cyanosis  or  other  vasomotor  disturb- 
ances ;  trophic  changes  are  frequent 
ulcerations,  bullae  and  even  gangrene 
causing  deformities.  The  deformities 
in  the  hands  are  asymmetric.  There 
is  loss  of  pain  and  temperature-senses, 
while .  the  ordinary  touch-sensation  is 
unaffected.  The  course  is  exceedingly 
chronic  and  nothing  influences  the 
course  of  the  disease. 

HEREDITARY  ATAXIA.1 

(Friedreich's  Ataxia.) 

Definition.  —  An  hereditary  or 
family  disease  characterized  by  ataxia. 

Etiology. — It  begins  in  early  life 
between  infancy  and  puberty.  In  some 
cases  the  hereditary  factor  cannot  be 
found. 

Pathology. — There  are  imperfect 
development  of  the  cord  and  sclerosis 
of  the  lateral  and  posterior  columns. 

Symptoms.  —  Usually  begins  in 
legs ;  child  walks  with  legs  far  apart  and  has  a  staggering  gait. 

1  Batten,  "  Ataxia  in  Childhood/'  Brain,  Autumn  and  Winter  Number, 
1905,  p.  484. 


Fig.  120.— Case  of  syrin- 
gomyelia with  areas  of 
thermo-anesthesia  marked 
in  black.  There  is  cervical 
kyphosis  (Church). 


DTSEASES  OF  THE  SPINAL   OOMD.  359 

hater  arms  are  affected  and  there  is  general  ataxia.  There  is  a 
nodding  of  the  head  and  a  coarse  tremor,  nystagmus,  scan- 
ning speech,  muscular  weakness,  scoliosis,  little  or  no  dis- 
turbance of  sensation,  a  hollow  foot  with  marked  extension 
of  the  big  toe.     The  deep  reflexes  are  usually  lost. 

Diagnosis. — From  locomotor  ataxia  by  the  absence  of 
Argyll-Robertson  pupil,  pains,  crises  and  anesthesia,  and  the 
presence  of  nodding,  nystagmus,  altered  speech,  and  general 
incoordination. 

Multiple  sclerosis  is  distinguished  by  the  marked  inten- 


Fig.  121.— Clubbed  foot  of  Friedreich's  disease,  showing  shortened  arch  and 
retracted  great  toe  (Church). 

tional  tremor,  spastic  gait,  increased  reflexes,  and  ocular 
paralysis. 

Prognosis. — The  disease  gets  steadily  worse,  and  in  a 
few  years  the  patient  is  crippled  and,  later,  becomes  de- 
mented. 

Treatment. — Symptomatic. 

CEREBELLAR  HEREDITARY  ATAXIA.     (Marie^ 

This  is  an  hereditary  affection  in  which  the  lesions  are  m 
the  cerebellum.     It  comes  on  about  puberty  or  later,  and  is 


360 


DISEASES  OF  INFANTS  AND   CHILDREN. 


distinguished  from  Friedreich's  ataxia  by  the  presence  of  in- 
creased patellar  reflexes,  absence  of  scoliosis  and  trophic 
changes. 

LANDRY'S  PARALYSIS. 

(Acute  Ascending  Paralysis.) 

This  is  rare  in  children.  It  is  characterized  by  a  flaccid 
paralysis,  beginning  in  the  legs  and  progressing  rapidly 
upward,  affecting  all  or  almost  all  the  muscles  of  the  body. 
The  reflexes  are  lost,  and  there  may  be  some  disturbance  of 
sensation.  Almost  all  the  cases  die  within  a  week  or  two. 
Recovery  may  take  place  with  disappearance  of  the  paralysis. 

ATROPHIES  OF  NERVOUS  ORIGIN. 

(Progressive  Central  Muscular  Atrophy.) 

These  are  rare  in  early  life,  usually  coming  on  after  puberty. 
They  are  due  to  changes  in  the  motor  cells  of  the  cord  and 


Fig.  122.— Kyphoscoliosis  in  extreme  muscular  atrophy. 

are  characterized  by  their  starting  in  the  periphery  (usually 
in  the  hands),  the  presence  of  fibrillary  contractions,  and  the 


DISEASES  OF  THE  SPINAL   CORD. 


361 


Fig.  123.— Extreme  muscular  atrophy. 


Fig.  124.— Pseudohypertrophic  muscular  paralysis  :  Postures  in  rising  to  the  erect 

position  (Gowers). 


362  DISEASES  OF  INFANTS  AND   CHILDREN 

reaction  of  degeneration.  Their  course  is  usually  progressive 
and  slow,  but  it  may  be  rapid. 

There  are  several  types,  as  follows  : 

Muscular  Atrophy  of  the  Duchenne-Aran  Type. — Beginning 
in  the  hands  and  extending  to  the  other  muscles  of  the  body. 
The  lesion  in  this  is  a  chronic  anterior  poliomyelitis.  There 
is  chronic  progressive  atrophy  of  the  muscles,  and  the  tendon 
reflexes  diminished  or  abolished. 

Amyotrophic  Lateral  Sclerosis  (Charcot's  Disease). — Where 
there  is  progressive  muscular  atrophy  with  increased  tendon 
reflexes. 

Glosso-labial-laryngeal  Paralysis. — Bulbar  paralysis — often 
seen  at  a  late  stage  of  the  preceding. 

Syringomyelia. — (See  same.) 

Chronic  Anterior  Poliomyelitis  of  Childhood  (Werdnig, 
1891). — A  family  disease  beginning  in  infancy,  characterized 
by  progessive  muscular  atrophy  and  great  muscular  weakness. 
It  resembles  in  a  general  way  the  adult  type  of  the  disease, 
but  the  following  contractions  are  wanting,  and  the  reaction 
of  degeneration  may  or  may  not  be  present.  It  progresses 
slowly,  death  usually  taking  place  within  four  years. 

The  progressive  Muscular  dystrophies. 

These  have  certain  features  in  common.  They  are  seen  in 
early  life ;  the  spinal  atrophies  usually  come  on  after  puberty. 
Hereditary  influences  are  common.  The  atrophy  is  usually 
symmetric  and  affects  the  muscles  of  the  limbs  near  the 
trunk  earlier  -and  to  a  greater  extent  than  the  distal  muscles. 
Fibrillary  contraction  of  the  muscles  is  generally  absent. 
The  tendon  reflexes  vary  with  the  amount  of  muscular  dis- 
turbance. There  are  frequently  contractions  of  portions  of 
the  muscle.  There  may  be  marked  retraction  of  some  of  the 
muscles  causing  deformities.  There  is  a  diminution  of  the 
electric  excitability  of  the  muscle,  but  no  reaction  of  de- 
generation. They  have  an  extremely  slow  course.  In  some 
there  may  be  at  the  outset  hypertrophy  of  the  muscle. 

Forms  of  the    Disease. — Facial-scapulohumeral   Type 


DISEASES   OF  THE  SPINAL    CORD. 


363 


Fig.  125. — Progressive  muscular  atrophy,  showing  hypotonia. 

(Landouzy-Dejerine). — {Progressive  Muscular  Paralysis  of 
Childhood,  of  Duchenne  of 
Boulogne.)  —  The  muscles 
of  the  face  aucl  the  scapulo- 
humeral group  are  first  af- 
fected. The  expression  is 
characteristic,  the  lips  not 
partaking  in  the  atrophy ; 
there  is  the  so-called  "  tapir 
face  "  ;  there  is  the  "  wing 
scapula."  Later  the  other 
muscles  of  the  body  atrophy. 

Scapulohumeral  Type 
(Erb). — Same  as  above,  ex- 
cept face  is  not  affected 
early. 

Pseudohypertrophic  Paral- 
ysis (Duchenne)  (Muscular 
Pseudohypertrophy}. — This 
is  more  frequent  in  boys. 
In  this  form  there  is  at 
the  start  an  hypertrophy  of 
some  of  the  muscles,  espe- 

.   -n  n.   tl  ,  r»   ,1  Fig.  126.— Pseudohypertrophic  paralysis. 

cially  oi  the  calves   ot  the 

legs,  but  often  of  other  muscles.     There  is  marked  loss  of 


364 


DISEASES  OF  INFANTS  AND   CHILDREN. 


power.  When  lying  on  the  floor  they  get  up  by  "climbing 
up,"  as  it  were,  by  resting  ihe  hands  on  the  legs.  Later 
there  is  atrophy. 


Fig.  127.—"  Winged  scapulae"  in  progressive  muscular  atrophy. 

Prognosis. — The  outlook  is  bad.  The  disease,  as 
a  rule,  gets  progressively  worse.  Occasionally  it  is 
arrested. 


1 


Fig.  128.— Progressive  muscular  atrophy  (Aran-Duchenne  type). 

Treatment. — Massage,  electricity,  and  general  hygiene. 


DISEASES   OE  THE  Sl'lSAL    colli). 


305 


PERONEAL    MUSCULAR   ATROPHY    (Charcot-Marie). 
Progressive   Neuritic   Muscular   Atrophy   (Hoffman.) 

A  disease  beginning  in  early  life  with  marked  atrophy  of 
the  muscles  of  the  feet  and  legs  ;  later  the  hands  and  forearms 


Fig.  129.-Hands  and  feet  in  muscular 
atrophy  of  the  Charcot-Marie  type. 


Fig.  130.— Muscular  atrophy  of    the 
Charcot-Marie  type  (P.  Marie). 


are  involved.  The  atrophy  is  extreme.  The  tendon  reflexes 
are  abolished.  Sensation  is  normal  or  slightly  disturbed. 
There  is  frequently  a  distinct  family  tendency. 

HYPERTROPHIC  INTERSTITIAL  NEURITIS   (Dejerine  and 

Sottas). 

This  is  a  disease  beginning  in  early  life,  sometimes  occur- 
ring as  a  family  disease.  It  resembles  the  preceding,  with 
the  addition  of  shooting  pains,  disturbances  and  retardation 


366  DISEASES  OF  INFANTS  AND   CHILDREN. 

of  sensation,  kyphoscoliosis,  Argyll-Robertson  pupil,  and 
marked  ataxia.  There  is  distinct  hypertrophy  of  the  periph- 
eral nerves.  Late  in  the  course  of  the  disease  there  is  the 
clinical  picture  of  locomotor  ataxia. 

MULTIPLE  NEURITIS. 

Definition. — An  inflammation  of  the  peripheral  nerves. 
It  may  affect  several  nerves,  usually  symmetrically,  or  it  may 
be  general. 

Etiology. — Diphtheria  and  occasionally  the  other  infec- 


Fig.  131.— Foot-drop  in  neuritis,  following  typhoid  fever. 

tious  diseases  ;  sometimes  exposure  or  cold  ;  and  rarely  alco- 
hol, arsenic,  or  lead. 

Pathology. — There  is  an  inflammation  of  the  affected 
nerve,  followed  by  more  or  less  complete  degeneration  of  the 
nerve-fibers. 

Symptoms. — The  onset  may  be  sudden,  with  chill  or 
convulsion  and  fever ;  generally,  however,  it  is  gradual. 
During  the  onset  there  is  pain,  with  great  sensitiveness  along 
the  course  of  the  nerve;  later  there  may  be  anesthesia. 
There  is  weakness ;  then  paralysis  of  the  muscle,  both  arms 
or  legs  or  all  four  may  be  affected,  and  the  extensors  of  the 


DISEASES  OF  THE  SPINAL   CORD.  367 

foot  and  hand  and  the  peroneal  and  muscular  spiral  nerves 
are  usually  most  severely  affected.  Tendon  reflexes  are  di- 
minished or  abolished  altogether,  and  reaction  of  degenera- 
tion. Marked  atrophy  follows.  Muscular  contractions  may 
cause  deformities. 

Diagnosis. — By  the  association   of  motor  and  sensory 
symptoms  to  the  course  of  the  affected  nerves.      When  the 


Fig.  132.— Dropped  wrist  from  musculospiral  palsy,  showing  retrocarpal  tumor 

(Church). 

back  muscles  are  affected  it  may  be  mistaken  for  Pott?s 
disease. 

Prognosis. — The  average  case  begins  to  improve  after 
the  first  month,  recovery  generally  being  complete  in  three 
months.  The  sensory  symptoms  clear  up  first.  In  some 
cases  the  paralysis  may  be  permanent  and  cases  may  even  be 
fatal. 

Treatment. — Rest  and  hot  applications  during  onset. 
Later,  electricity  as  in  infantile  spinal  paralysis.  Strychnia 
and  tonics. 


368  DISEASES  OF  INFANTS  AND   CHILDREN. 


FACIAL  PARALYSIS.1 

(Bell's  Palsy.) 

The  paralysis  may  be  due  to  lesioDS  in  the  skull,  in  the 
petrous  bone,  or  in  the  peripheral  part  of  the  nerve. 

The  most  frequent  cause  is  neuritis.  This  is  usually  due 
to  middle-ear  disease  and  affects  the  nerve  in  the  bony  canal. 
Many  cases  set  down  to  "  cold"  are  of  this  form  (Reik).  Inside 
the  skull  the  lesion  may  cause  meningitis,  tumor,  or  injuries 
to  the  skull ;  in  the  peripheral  part  inflammation  of  the 
lymph  glands  of  the  neck  or  mumps. 

Symptoms. — There  is  paralysis  of  the  muscles  of  one 
side  of  face ;  it  is  smooth  and  does  not  change  on  closing 
eyes,  laughing,  etc.     Sensation  is  good. 

Diagnosis. — The  causes  due  to  central  trouble  do  not 
affect  the  upper  fibers ;  so  the  forehead  is  unaffected.  At 
the  base  of  the  brain  the  auditory  nerve  is  also  involved,  and 
there  is  deafness  without  ear  lesions.  The  ear  trouble  is 
evident,  if  looked  for  in  the  cases  affecting  the  canal. 

Prognosis. — This  depends  upon  the  cause.  The  cases 
due  to  "  cold  "  usually  recover  in  a  month  or  two. 

Treatment. — Treat  the  ear  where  it  is  a  cause.  Later, 
electricity  as  in  spinal  paralysis.  Central  cases  are  unaffected 
by  local  treatment. 


DIPHTHERITIC  PARALYSIS. 

The  paralyses,  coming  on  early,  are  supposed  to  be  due  to 
the  soluble  toxins  in  the  blood,  and  they  are  a  part  of  the 
picture  of  the  toxemia. 

The  late  paralyses,  coming  on  after  the  first  week  after  the 
acute  stage  of  the  disease  and  as  late  as  the  sixth  week,  gen- 
erally result  where  there  has  been  an  extensive  membrane 
with  severe  toxemia.  It  usually  begins  in  the  uvula  or  the 
larynx,  and  may  spread  to  other  muscles  supplied  by  cranial 

1  Taylor  and  Clark,  "  Facial  Palsy,  Results  of  Faciohypoglossal  Anasto- 
mosis for,"  Jour.  Amer.  Med.  Assoc,  March  24, 1906,  p.  856.  Rainy  and  Fow- 
ler, ''Facial  Paralysis,"  Review  of  Neurology  and  Psychiatry,  March,  1903. 


DISEASES  OF  THE  SPINAL   CORD.  369 

nerves  or  to  the  extremities.  Usually  there  is  a  generalized 
muscular  asthenia  (and  not  an  absolute  loss  by  muscular 
innervation),  flaccidity,  muscular  hypotonus,  and  loss  of 
tendon  reflexes.  Voluntary  movements  to  a  very  slight 
degree  can  generally  be  made. 

When  the  soft  palate  is  affected,  attempts  to  swallow  fluids 
result  in  their  return  through  the  nose.  This  may  be  the 
earliest  symptom.  If  the  paralysis  extends  to  the  pharynx, 
swallowing  may  be  difficult  or  impossible.  The  muscles  of 
accommodation  may  be  involved,  as  well  as  the  external 
muscles  of  the  eye,  the  latter  causing  strabismus  and  double 
vision. 

The  prognosis  is  good,  recovery  taking  place  usually 
within  two  months,  sometimes  later,  but  it  must  be  remem- 
bered that  fatal  cases  occur  where  the  heart  or  respiration  or 
muscles  of  deglutition  are  involved. 

The  treatment  consists  in  rest  in  bed.  Gavage  may  be 
necessary  if  the  child  cannot  swallow.  Strychnin  and  atro- 
pin  are  the  most  useful  stimulants  if  the  heart  and  respira- 
tion become  affected. 

24 


370  DISEASES  OF  INFANTS  AND   CHILDREN. 

ACUTE  INFECTIOUS  DISEASES* 
THE  TRANSMISSION  OF  INFECTIOUS  DISEASES.1 

Infectious  diseases  are  transmitted  in  several  ways.  Per- 
haps most  frequently  the  patient  transmits  the  disease  directly, 
as  in  the  case  of  diphtheria  or  measles.  Mild  and  unrecog- 
nized cases  of  the  disease  are  an  especial  source  of  danger,  as 
they  mingle  freely  with  others.  Some  diseases  may  be  trans- 
mitted by  an  individual  apparently  in  perfect  health,  who 
has  been  associated  with  some  one  who  has  the  disease,  and 
harbors  in  his  mouth  or  elsewhere  the  disease-producing 
germs.  Such  an  individual  is  called  a  disease  carrier.  In 
some  instances  the  disease  may  also  be  transmitted  by  objects 
which  have  come  in  contact  with  the  sick  person  or  with  his 
discharges,  and  such  objects  are  spoken  of  under  the  head  of 
fomites.  In  other  instances  an  intermediate  host  is  required, 
and  is  usually  an  insect  which  takes  the  infectious  material 
into  its  body  and  transmits  it  later  on  to  human  beings,  and, 
lastly,  some  diseases  may  be  transmitted  through  the  air,  but 
this  happens  rarely  and  under  exceptional  circumstances. 
Air  infection  is  possible  over  a  small  range  in  measles  and 
chicken-pox.  In  whooping-cough,  during  the  paroxysm,  the 
patient  causes  a  small  spray  of  mucus  and  saliva  which  may 
infect  the  air  for  a  short  time  for  a  few  feet  in  front  of  him. 
The  transmission  of  disease  by  fomites  is  probably  not  as 
great  a  danger  as  was  formerly  supposed,  and  with  rational 
disinfection  of  infected  articles  there  is  no  danger  at  all. 

In  a  general  way  it  may  be  stated  that  patients  having 
infectious  diseases  should  be  isolated,  as  the  fewer  people  who 
come  in  contact  with  the  disease  the  fewer  will  get  it.  The 
patient  should  be  protected  from  mosquitoes,  flies,  and  other 
insects,  especially  from  mosquitoes  in  case  of  yellow  fever 
and  malaria,  from  flies  in  case  of  typhoid  fever  and  cholera, 
and  from  fleas  in  case  of  plague. 

1  Doty,  American  Journal  of  Medical  Sciences,  July,  1909,  p.  30.  Edsall, 
Journal  of  the  American  Medical  Association,  July  9,  1909,  p.  123.  Chapin, 
Ibid.,  December  12,  1908,  p.  2048. 


ACUTE  INFECTIOUS  DISEASES.  371 

SCARLET  FEVER-SCARLATINA. 

Definition. — An  acute  infectious  disease  characterized  by 
a  sudden  onset,  vomiting,  a  scarlet  rash,  sore  throat,  high 
fever  and  rapid  pulse,  and  a  tendency  to  nephritis.  There 
are  great  variations  in  the  intensity  and  character  of  the  dis- 
ease. 

Etiology. — The  disease  is  communicated  by  direct  con- 
tact, by  fomites,  and  it  may  be  carried  by  a  third  person. 
The  poison  lingers  for  a  long  time  and  may  remain  active  for 
a  year  or  more.  Epidemics  have  been  started  by  infected 
milk.  The  disease  is  infectious  from  the  onset  until  after 
desquamation  has  been  completed.  About  50  per  cent,  of 
the  persons  exposed  take  the  disease.  The  susceptibility  is 
greatest  between  three  and  six  years  of  age  and  diminishes 
with  age.  After  fifteen  the  disease  is  not  common.  Fall, 
winter,  and  spring  are  the  seasons  of  greatest  prevalence  ;  in 
other  words,  when  people  are  crowded  together  indoors  or 
when  the  schools  are  in  session.  The  disease  is  much  less 
common  in  the  tropics,  and  is  practically  unknown  near  the 
equator,  while  in  the  cities  where  there  are  tenements  it  is 
especially  common.  One  attack  usually  produces  immunity, 
and  second  attacks  rarely  occur.  The  specific  organism  has 
not  been  definitely  isolated.  Streptococci  are  almost  con- 
stantly associated  with  the  disease,  and  are  doubtless  respon- 
sible for  many  of  the  symptoms.  Mallory,  of  Boston,  has 
described  a  parasite  in  the  skin  of  scarlet  fever  patients. 

Pathology. — The  macroscopic  skin  changes  are  not 
noted  after  death.  Microscopically  the  changes  in  the  skin 
consist  of  dilatation  of  the  blood-  and  lymph- vessels  just  be- 
neath the  epidermis  and  in  the  papilla?,  together  with  vary- 
ing amounts  of  exudation.  The  same  is  true  of  the  mucous 
membranes  of  the  pharynx,  soft  palate,  tonsils,  and  also  of 
the  tongue  when  the  papilla?  are  markedly  affected,  causing 
macroscopic  enlargement.  Inflammation  of  varying  extent 
and  intensity  is  seen  in  the  throat  and,  in  some  cases,  a  false 
membrane  may  be  present.  The  lymph-nodes  of  the  neck 
are  enlarged.  There  are  degenerations  in  the  muscles  and 
also  in  the  heart  muscles.     There  may  be  endocarditis,  peri- 


372  DISEASES   OE  INFANTS  AND   CHILDREN. 

carditis,  or  myocarditis.  The  spleen  and  liver  may  be  en- 
larged. The  kidneys  show  marked  changes,  usually  a  glom- 
erulonephritis of  a  hemorrhagic  form. 

Incubation. — This  is  difficult  to  determine,  and  is  appar- 
ently somewhat  variable.  Cases  are  said  to  develop  as  early 
as  twenty-four  hours  and  as  late  as  twenty-one  days  after 
exposure.  The  consensus  of  opinion  is  that  the  period  is 
usually  short,  from  two  to  six  days. 

Onset. — The  disease  begins  suddenly,  usually  with  an 
attack  of  vomiting;  fever  is  high,  often  104°  and  105°  F. 

Eruption. — This  appears  on  the  first  or  second  day,  first  on 
the  neck  and  chest,  and  from  there  spreads  over  the  entire 
body.  It  consists  of  a  more  or  less  uniform  scarlet  blush  or 
of  fine  punctate  spots  set  closely  together.  The  lips  are  not 
affected.  The  rash  disappears  on  pressure  and  returns  the 
moment  that  pressure  is  removed.  It  is  usually  punctate  in 
the  groins,  axilla,  and  roof  of  the  mouth.  It  lasts  from 
three  to  seven  days,  when  it  gradually  fades,  and  is  followed 
by  a  desquamation  lasting  from  two  to  six  weeks.  The 
desquamation,  if  the  skin  is  not  cared  for,  usually  takes  place 
in  large  pieces.  There  are  many  variations  from  this  typical 
rash.  It  may  be  pale  and  transient,  or  there  may  be  miliaria 
and,  in  severe  cases,  purpura. 

Tongue. — This  is  quite  characteristic.  On  the  first  day  it 
is  furred,  then  the  enlarged  papilla?  show  through  the  white 
surface  (strawberry  tongue).  In  three  or  four  days  the  white 
disappears,  leaving  a  red  tongue  Avith  enlarged  papillae  (mul- 
berry tongue).  Sometimes  the  enlargement  of  the  papillae 
may  be  the  only  sign. 

Throat  Symptoms. — These  vary  greatly.  In  mild  cases 
there  is  only  redness  of  the  pharynx.  In  moderate  cases 
there  is  enlargement  of  the  tonsils,  some  patches  of  membrane, 
and  great  redness  of  the  entire  throat.  In  the  severe  or 
anginoid  cases  there  is  a  marked  membranous  angina  with 
involvement  of  the  pharynx,  sAvelling  of  the  lymph-nodes 
and  other  tissues  of  the  neck,  and  this  condition  may  be 
mistaken  for  diphtheria.  Suppuration  or  a  gangrene  may 
follow. 


ACUTE  INFECTIOUS  DISEASES.  373 

General  Symptoms. — The  onset  is  sudden,  and  gen- 
erally corresponds  in  severity  with  the  character  of  the  dis- 
ease later  on.  Vomiting  is  commonly  noted,  and  there  is 
usually  also  sore  throat  and  high  fever;  the  temperature  rises 
rapidly,  and  usually  reaches  its  highest  point  (104°  to 
105°  F.)  on  the  first  or  second  day.  In  uncomplicated  and 
not  very  severe  cases  it  gradually  falls  and  becomes  normal 
in  from  four  to  seven  days  or  more.  A  recurrence  of  the 
fever  nearly  always  means  some  complication.  The  pulse  is 
rapid,  the  digestion  is  disturbed,  there  is  scanty,  high-colored 
urine  which  often  contains  albumin.  There  arc  restlessness, 
headache,  and  there  may  be  delirium  or  coma.  The  blood 
shows  a  marked  leukocytosis.  The  cases  may  be  classified 
as  mild,  moderately  severe,  auginoid,  and  malignant.  The 
very  mild  cases  may  be  overlooked.  There  is  usually  fever, 
sore  throat,  and  the  rash  is  most  marked  on  the  body.  The 
eruption  and  symptoms  disappear  in  from  three  to  five  days. 
In  cases  of  moderate  severity  all  the  symptoms  are  generally 
present  and  last  from  a  week  to  ten  days. 

Anginoid  Scarlet  Fever. — These  are  severe  cases, 
with  marked  throat  symptoms.  There  is  a  membrane  over 
the  tonsils,  the  throat  is  swollen  and  reddened,  and  there  is 
usually  involvement  of  the  cellular  tissues  of  the  neck, 
together  with  enlargement  of  the  lyinph-nodes. 

Malignant  Scarlet  Fever. — This  may  come  on  sud- 
denly with  hyperpyrexia  and  coma  (atactic  form),  death  tak- 
ing place  within  the  first  two  days,  or  it  may  be  of  the 
hemorrhagic  variety,  when  there  is  a  purpuric  rash  and  also 
hemorrhages  from  the  mucous  membranes.  Death  usually 
occurs  within  three  or  four  days. 

Relapses  or  recurrences  are  often  seen,  the  disease  appar- 
ently subsiding  and  then  recurring,  with  the  reappearance  of 
all  or  nearly  all  the  symptoms. 

Second  attacks  are  rare,  the  immunity  conferred  by  the 
first  attack  being  quite  perfect.  Second  attacks  are  occasion- 
ally noted,  however,  and  there  are  cases  on  record  where  the 
child  has  had  three  attacks.  One  must  bear  in  mind  the 
frequent  errors  in  diagnosis  in  this  connection. 


374  DISEASES  OF  INFANTS  AND   CHILDREN. 

Complications. — These  are  numerous  and  important. 
Albuminuria  is  of  very  common  occurrence  and  nephritis  is 
also  frequent.  The  latter  comes  on  most  frequently  during 
the  second  or  third  week  of  the  disease,  or  even  later,  and 
presents  the  usual  features  of  nephritis.  It  may  be  mild  or 
severe,  and  chronic  nephritis  may  result.  Otitis  media  is 
very  frequent,  and  may  result  in  deafness  or  impaired  hear- 
ing, or  by  extension  to  meningitis.  Acute  endocarditis,  peri- 
carditis, and  myocarditis  may  occur,  and  inflammation  of 
other  organs  and  tissues,  such  as  pneumonia  and  pleurisy, 
are  not  infrequent.  The  lymph-nodes,  especially  those  of 
the  neck,  are  enlarged  and  sometimes  suppurate. 

Diagnosis.1 — This  is,  as  a  rule,  easy,  but  at  times  it  may 
be  difficult,  chiefly  owing  to  the  variations  in  the  rash.  Skin 
eruptions  resembling  scarlet  fever  are  so  common  that  it  is 
never  safe  to  make  the  diagnosis  on  the  rash  alone.  In 
doubtful  cases  the  entire  body  should  be  inspected,  special 
attention  being  paid  to  the  groins,  axillae,  and  back.  It  is 
most  frequently  confused  with  the  following : 

Acute  Exfoliative  Dermatitis. — This  may  occur  again  and 
again.  It  resembles  scarlet  fever  closely,  having  a  sudden 
onset,  fever  lasting  a  week  or  so,  and  is  followed  by  desqua- 
mation. The  desquamation  is  more  marked  than  in  scarlet 
fever,  the  tongue  and  throat  are  usually  unaffected,  and  the 
nails  and  hair  are  involved. 

Measles. — The  longer  period  of  invasion,  the  catar- 
rhal symptoms,  the  characteristic  rash,  Koplik's  spots, 
and  the  absence  of  leukocytosis  should  make  the  diagnosis 
easy. 

German  Measles. — The  enlarged  lymph-glands,  mild  or 
no  throat  symptoms,  polymorphous  rash,  and  absence 
of  constitutional  disturbance  usually  make  the  diagnosis 
clear. 

Diphtheria. — It   may   be  difficult  to  tell  without  cultures 

1  Whitfield,  "  Rashes  of  Scarlet  Fever  and  Other  Skin  Eruptions,"  Prac- 
titioner, January,  1909,  p.  62.  Beggs,  "  Differential  Diagnosis  of  Scarlet 
Fever,"  Practitioner,  January,  1909,  p.  52.  Cuff,  "  Diagnosis  of  Scarlet 
Fever  and  Diphtheria,"  Practitioner,  January,  1909,  p.  47.  Goodall,  "  Diag- 
nosis of  Scarlet  Fever,"  Practitioner,  January,  1909,  p.  38. 


ACUTE  INFECTIOUS  DISEASES.  375 

whether  one  has  a  diphtheria  with  a  rash  or  a  scarlet 
fever  with  a  bad  throat.  One  shonld  bear  in  mind  that 
the  former  is  the  exception,  the  latter  the  rule.  The  history 
of  exposure  and  the  persistence  of  the  rash  in  scarlet  fever  are 
of  value 

Septicemia. — There  may  be  scarlet  rashes  in  blood  poison- 
ing having  exactly  the  same  appearance  as  scarlet  fever. 

Drug  Rashes. — These  may  follow  the  use  of  antipyrin, 
quinin,  belladonna,  copaiba,  potassium  iodic!,  diphtheria 
antitoxin,  etc.  They  are  not,  as  a  rule,  attended  with  fever, 
and  are  usually  transient. 

Prognosis. — The  mortality  varies  in  different  epidem- 
ics. As  a  rule,  the  younger  the  child  the  worse  the  prog- 
nosis. The  mortality  varies  from  5  to  20  or  even  30  per 
cent.      ' 

Treatment. — The  child  should  be  isolated,  and  similar 
prophylactic  precautions  taken  to  those  recommended  in 
diphtheria.  The  child  should  be  kept  in  bed  throughout  the 
entire  attack,  and  in  severe  cases  from  one  to  two  weeks  after- 
ward. The  diet  should  consist  of  milk  or  milk  and  cereals 
for  at  least  a  month.  By  following  this  dietetic  treatment  the 
cases  of  nephritis  are  reduced  to  a  minimum.  Cold  packs  or 
sponges  mav  be  used  to  reduce  high  fever  (over  103°  or 
104°  F.),  also  to  relieve  nervousness,  delirium,  and  sleepless- 
ness. Cold  may  be  applied  to  the  head  for  headache  and  to 
the  throat  when  there  is  adenitis.  The  throat  may  be 
sprayed,  as  in  diphtheria.  Stimulants  may  be  used  as  indi- 
cated. Iron  and  strychnin  may  be  given  if  necessary  during 
convalescence.  The  skin  should  be  thoroughly  cleansed  once 
or  twice  a  day,  and  anointed  with  equal  parts  of  lanolin  and 
vaselin  or  some  other  ointment.  This  facilitates  desquama- 
tion and  prevents  the  fine  scales  of  epidermis  from  flying 
about. 

MEASLES. 

Definition. — Measles  is  a  specific,  acute,  infectious  dis- 
ease characterized  by  extreme  contagiousness,  catarrhal  symp- 
toms, fever,  Koplik   spots,  and  a  characteristic  red  papular 


376 


DISEASES  OE  INFANTS  AND   CHILDREN. 


eruption,  which    usually  appears  on  the  fourth  day,  and  a 
branny  desquamation  during  convalescence. 

Etiology. — Measles  is  one  of  the  most  contagious  dis- 
eases. Infection  is  usually  by  direct  contact.  It  may  result 
from  being  in  the  same  room,  as  the  contagion  can  be  carried 
through  the  air  for  a  short  distance.  It  may  be  carried  by 
fomites  or  a  third  person,  but  this  is  rarely  the  case.  The 
disease  is  contagious  during  the  latter  part  of  the  incubation 
period  and  throughout  the  course  of  the  disease.  Suscepti- 
bility is  very  great  and  very  few  are  naturally  immune.  It 
is  seen  most  frequently  in  childhood.  It  is  endemic  in  the 
larger  cities  and  also  occurs  in  epidemics,  most  frequently  in 
winter.     One  attack  confers  immunity,  but  second  attacks 


Fig.  loo.— Measles  temperature 
chart.    Mild  case. 


Fig.  134. — Measles  temperature  chart,  showing 
initial  rise  and  fall. 


may  occasionally  occur.  No  specific  organism  has  as  yet 
been  isolated. 

Pathology. — There  is  a  catarrhal  condition  of  the  res- 
piratory tract,  and  often  of  the  gastro-intestinal  tract  as  well. 
Measles  itself  rarely  kills,  and  in  fatal  cases  bronchopneu- 
monia is  the  most  frequently  observed  lesion. 

Period  of  Incubation. — This  is  variously  stated,  as  to 
whether  one  counts  to  the  appearance  of  the  symptoms  or  to 
the  appearance  of  the  eruption.  Symptoms  appear  from  nine 
to  eleven  days  and  the  rash  quite  uniformly  on  the  thirteenth 
or  fourteenth  day  after  infection. 

Symptoms. — Invasion. — There  may  be  languor  for  some 


1. 


The  pathognomonic  sign  of  measles  (Koplik's  spots). 

1.  The  discrete  measles-spots  on  the  buccal  or  labial  mucous  membrane,  show- 
ing the  isolated  rose-red  spot,  with  the  minute  bluish-white  center,  on  the  nor- 
mally colored  mucous  membrane.  2.  The  partially  diffuse  eruption  on  the  mucous 
membrane  of  the  cheeks  and  lips ;  patches  of  pale  pink  interspersed  among  rose- 
red  patches,  the  latter  showing  numerous  pale  bluish-white  spots.  3.  The  appear- 
ance of  the  buccal  or  labial  mucous  membrane  when  the  measles-spots  completely 
coalesce  and  give  a  diffuse  redness,  with  the  myriads  of  bluish-white  specks.  The 
exanthem  is  at  this  time  generally  fully  developed.  4.  Aphthous  stomatitis,  likely 
to  be  mistaken  for  measles-spots.  Mucous  membrane  normal  in  hue.  Minute  yellow 
points  are  surrounded  by  a  red  area.    Always  discrete.    (Medical  News,  June  3, 1899.) 


ACUTE  INFECTIOUS  DISEASES. 


377 


davs,  with  drowsiness  and  then  coryza,  cough,  headache, 
nausea,  and  lever.  The  temperature  usually  reaches  its 
height  (about  104°  F.)  on   the   second   day,  but  may   begin 


100 
106 
104 
103 
102 
101 
100 
OO 
90 


i  i  ■ 

;  i-P-;4-  !    •      •       •       I 


-       • 


Fig.  135.— Measles  temperature  chart,  showing  sudden  fall  at  the  appearance  of  the 

eruption. 

abruptly  and  drop,  to  ascend  later.  After  the  second  day  the 
temperature  gradually  falls  and  reaches  normal  in  about  a 
week.     The  temperature  varies  with  the  severity  of  the  case. 


Fig.  136.— Measles  temperature  chart.    Case  of  moderate  severity,  showing  rather 
abrupt  rise  at  beginning  of  eruption. 


Subsequent  rises  in  temperature  are  almost  invariably  caused 
by  complications. 

Koplik's  Spots. — These  are  of  great  value  in  diagnosis. 
They  appear  usually  the  day  before  the  eruption,  but  often 
twOj  three,  or  even  four  days  before.     They  are  best  seen  on 


378 


DISEASES  OF  INFANTS  AND   CHILDREN. 


the  inner  side  of  the  cheeks  on  a  level  with  the  second  molars, 
and  consist  of  small  bluish-white  specks  with  a  red  areola. 
The  white  spot  disappears  early,  leaving  a  little  red  spot 
about  the  size  of  a  pin  head.     The  bluish-white  spots  must 


Fig.  137.— Measles  temperature  chart,  showing  a  complicating  pneumonia  coming 
on  after  the  temperature  had  fallen  to  normal. 

be  looked  for  in  daylight,  as  it  is  difficult  or  impossible  to 
see  them  by  artificial  light.  As  the  skin  eruption  begins  to 
appear  the  eruption  on  the  mucous  membranes  becomes  dif- 
fuse and  the  spots  are  lost  in  the  general  redness. 


Fig.  138.— Measles  temperature  chart,  showing  pneumonia  complicating  the  case 

from  the  sixth  day. 

Eruption. — This  appears  on  the  fourth  day,  although  some- 
times on  the  third  or  fifth  days.  It  is  first  seen  on  the 
forehead,  cheeks,  along  the  margin  of  the  hair  and  back  of 
the  ears,  and  then  on  the  face,  back,  sides,  arms,  front  of  the 


From  a  case  of  measles.     (Photograph  by  Dr.  Jay  F.  Schambexg.) 


ACUTE  INFECTIOUS  DISEASES.  379 

body,  and  legs.  It  consists  of  small  papules  about  the  size 
of  a  pin  head,  which  have  a  tendency  to  group  themselves  in 
crescentic  patches.  In  many  places  these  patches  may  be 
confluent.  The  rash  often  has  a  distinct  shot-like  feel,  the 
skin  is  hot  and  itches.  The  early  spots  are  a  rose-red  color 
and  rather  bright,  and  later  the  color  somewhat  resembles 
that  of  a  purple  raspberry,  becoming  darker  as  it  grows 
older.  After  several  days  it  fades  rather  quickly,  leaving 
purplish  brown  spots,  which  in  a  day  or  two  become  faint 
yellowish  brown  in  color.  This  slight  pigmentation  persists 
for  two  or  three  weeks.  The  rash  is  followed  by  a  fine, 
branny  desquamation.  There  may  be  atypical  cases,  and 
many  variations  of  the  rash  have  been  described.  The  erup- 
tion may  be  hemorrhagic  (black  measles),  and  this  form  is 
usually  very  severe.  The  rash  is  more  intense  in  a  warm 
room  or  in  a  warm  bed,  and  exposure  to  cold  may  cause  the 
rash  to  fade  somewhat. 

Other  Symptoms. — During  the  height  of  the  disease  the 
patient  is  usually  quite  uncomfortable,  there  is  marked  inflam- 
mation of  all  of  the  mucous  membranes,  there  is  conjunc- 
tivitis and  more  or  less  photobia  and  marked  coryza,  with 
considerable  discharge  from  the  nose.  The  mucous  mem- 
branes of  the  mouth  and  throat  are  intensely  reddened,  there 
is  a  bronchitis,  and  usually  a  marked  disturbing  cough. 
Albuminuria  is  usually  present,  vomiting  is  not  uncommon, 
and  sometimes  there  is  diarrhea.  There  is  leukocytosis  be- 
ginning early  in  the  period  of  incubation,  reaching  its  maxi- 
mum six  days  before  the  appearance  of  the  eruption,  and 
lasting  into  the  first  part  of  the  stage  of  invasion,  then  the 
leukocytes  fall  to  normal,  or  there  may  be  leukopenia.  Dur- 
ing the  eruptive  period  a  leukocytosis  means  a  complica- 
tion, although  complications  may  exist  without  any  leuko- 
cytosis. 

Complications  and  Sequelae, — These  are  very  numer- 
ous. Bronchopneumonia  is  most  common  and  may  be  the 
cause  of  death.  Laryngitis  is  also  frequently  seen.  Lobar 
pneumonia,  empyema,  and  gangrene  of  the  lung  may  all  be 
noted.      Gangrenous  stomatitis    sometimes  follows  in  weak 


380  DISEASES  OF  INFANTS  AND   CHILDREN. 

children.  Paralysis  is  sometimes  seen  and  occasionally  in- 
flammation of  the  joints  and  bones.  Tuberculosis  may  be 
seen  following  measles,  and  the  resistance  to  all  infectious 
diseases  is  lowered. 

Diagnosis  is  usually  easy. 

Scarlet  Fever. — This  is  distinguished  by  the  sudden  onset 
with  fever,  the  absence  of  catarrhal  symptoms  and  Koplik 
spots,  the  characteristic  eruption,  the  strawberry  tongue,  the 
angina,  and  the  presence  of  leukocytosis. 

German  Measles. — This  differs  in  the  more  rapid  invasion, 
the  polymorphous  character  of  the  rash,  the  absence  of  Kop- 
lik spots,  and  of  symptoms. 

Drug  Eruptions.— Copaiba  and  other  drugs  may  give  a  rash 
which  often  quite  closely  resembles  measles.  The  diagnosis 
is  made  on  the  history  of  the  administration  of  the  drug,  the 
absence  of  fever  and  other  symptoms,  the  absence  of  Koplik 
spots,  and  the  shorter  duration. 

Prognosis. — This  varies  in  different  epidemics.  It  may 
prove  very  fatal  at  times,  rarely  from  the  disease,  but  from 
complications,  especially  bronchopneumonia. 

Prophylaxis. — Care  should  be  taken  to  prevent  infec- 
tion, especially  of  young  children.  Isolation  is  not  effective 
unless  the  patient  is  separated  from  others  by  an  open-air 
space.  Susceptible  children  should  be  sent  away  as  soon  as 
the  disease  is  discovered,  and  if  this  is  not  done  promptly 
infection  usually  takes  place.  Isolation  in  the  average 
household  is  usually  either  started  too  late  or  is  not  strict 
enough  to  be  of  service.  In  hospitals  and  institutions  the 
rooms  occupied  by  the  patient  should  be  disinfected,  and  also 
in  private  houses  if  the  room  is  to  be  occupied  immediately 
by  susceptible  children.  If  two  or  three  weeks  elapse  there 
is  no  danger  from  infection. 

Treatment. — The  children  should  be  kept  in  a  well- 
ventilated  room  with  a  temperature  of  70°  F.  and  not  over- 
heated. The  skin  may  be  anointed  with  equal  parts  of  vase- 
lin  and  lanolin,  and  kept  clean  by  sponging  with  warm 
water  and  Castile  soap.  The  itching  may  be  relieved  by 
using  carbolized  vaselin  or  the  free  use  of  powder.     High 


ACUTE  INFECTIOUS  DISEASES.  381 

fever  and   restlessness  are  best  treated  by  sponge-baths  or 

cold  ] >acks.  The  mouth  and  nose  may  be  sprayed  with 
Dobell's  solution  and  a  boric  acid  eye-wash  used  for  the 
conjunctivitis. 

GERMAN  MEASLES. 
(Rubella;   Rotheln;  Epidemic  Roseola.) 

Definition. — Rubella  is  a  specific  infectious  disease  oc- 
curring in  epidemics,  and  characterized  by  a  polymorphous 
rash  which  sometimes  resembles  that  of  measles,  sometimes 
that  of  scarlet  fever,  and  sometimes  that  of  both  diseases, 
but  differing  from  them  in  incubation,  invasion,  in  having 
no  symptoms  and  no  dangerous  sequela?,  and  by  an  almost 
constant  enlargement  of  the  cervical  and  sometimes  other 
lymph-nodes. 

Etiology. — Rubella  exists  as  a  separate  disease,  and  it 
does  not  protect  against  either  scarlet  fever  or  measles.  It 
is  contagious  throughout  the  attack,  and  epidemics  are  most 
frequent  in  spring  or  winter,  but  the  disease  may  occur  spo- 
radically. It  rarely  affects  children  under  six  months,  but 
after  that  age  the  susceptibility  is  rather  general.  One  attack 
usually  confers  immuuity.  It  is  usually  transmitted  by 
direct  contact,  although  occasionally  by  fomites.  The  con- 
tagiousness seems  to  vary  in  different  epidemics,  being  slightly 
so  in  some  and  intensely  so  in  others.  It  is  more  common 
among  the  poor,  which  may  be  explained  by  the  lesser  resist- 
ance and  greater  danger  to  exposure. 

Period  of  incubation  is  from  five  days  to  three  weeks 
or  longer,  usually  from  ten  to  sixteen  days. 

Symptoms. — Prodromes  are  slight  or  absent.  The 
stage  of  invasion  lasts  but  a  day  or  less,  and  during  this 
time  there  may  be  slight  drowsiness,  sometimes  slight  fever, 
sore  throat,  and  more  rarely  a  chill  or  vomiting.  The  erup- 
tion begins  on  the  first  or  second  day,  and  in  many  instances 
the  child  wakes  up  with  the  eruption,  nothing  having  been 
previously  noted. 

Eruption. — This   begins  on  the  face,  and   spreads  rapidly 


382  DISEASES  OF  INFANTS  AND  CHILDREN. 

over  the  body  to  the  ends  of  the  extremities,  usually  in  one 
day.  It  lasts  two  to  four  days  and  occasionally  longer,  and 
when  it  fades  it  leaves,  especially  in  brunettes,  a  slight  pig- 
mentation, which  disappears  in  a  day  or  two.  One  of  the 
characteristics  of  the  rash  is  its  polymorphous  character.  It 
may  resemble  measles  (rubella  morbilliforme),  or  it  may  be  a 
more  uniform  blush,  like  scarlet  fever  (rubella  scarlatini- 
forme),  or  there  may  be  combinations  and  all  gradations 
between  the  two.  The  scarlatiniform  eruption  is  liable  to 
occur  where  there  is  pressure  upon  the  skin,  as  around  the 
waist-band  or  on  the  buttocks.  Slight  desquamation  follows. 
The  eruption  may  be  seen  on  the  mucous  membranes  in  small 
red  points  somewhat  raised  above  the  surface  on  the  uvula 
and  soft  palate  during  the  first  day,  and  is  of  some  value  in 
diagnosis.  During  the  attack  there  are  slight  fever,  a  little 
malaise,  and  swelling  of  the  lymph-nodes,  especially  of  the 
posterior  cervical  nodes,  which  may  attain  the  size  of  a 
pigeon's  egg. 

Blood. — Blood  findings  resemble  those  in  measles.  There 
is  a  leukocytosis  during  the  incubation,  followed  by  leuko- 
penia when  the  eruption  appears.  After  the  disappearance 
of  the   eruption  the  blood  becomes  normal. 

Complications  are  rare,  as  are  also  recurrences  and  relapses. 

Diagnosis. — The  polymorphous  rash,  the  eruption  on 
the  uvula  and  soft  palate,  and  the  glandular  enlargement 
with  an  absence  of  other  symptoms,  are  the  most  important 
features.  It  is  not  safe  to  diagnose  German  measles  apart 
from  an  epidemic.  The  absence  of  Koplik  spots  is  of  value 
in  excluding  measles,  and  the  rashes  due  to  heat,  indigestion, 
and  to  drugs,  so  common  in  infancy,  should  be  carefully 
excluded.  The  rash  caused  by  handling  certain  varieties  of 
caterpillars  should  not  be  mistaken  for  rubella. 

Prognosis. — This  is  almost  invariably  good.  Compli- 
cations and  fatalities  are  exceptional. 

Treatment. — As  a  rule,  none  is  required.  The  patient 
may  be  isolated  if  in  school  or  an  institution. 


ACUTE  INFECTIOUS  DISEASES. 


383 


DIFFERENTIAL   DIAGNOSIS  OF  RUBELLA,  SCARLET  FEVER, 
MEASLES,  AND  ERYTHEMA  INFECTIOSUM.1 


RVBELLA.  r 


MEASLES. 


Contagion. 


Apparently  va- 
ries in  "  epi- 
demics. Di- 
rect contact. 
Possibly  from 
fomites,  not 
through  the 
air. 


Highly  conta- 
gious. By  di- 
rect contact. 
By  fomites. 
Through  the 
air. 


SCARLET 
FEVER. 

Marked.  By  di- 
rect contact. 
By  fomites. 


Incubation. 


Prodromes. 


Variable   aver-    Average  9  to  14 
age,     4  to     3      days, 
weeks. 


Average  1 
davs. 


to  6 


Slight  and  of 
short  dura- 
tion. 0  c  c  a  - 
sionallya  day 
or  two  of 
malaise. 


Koplik  spots.       None. 


Vomiting. 
Fever. 


Rare. 

Slight  —  aver- 
age 1  to  2 
days,  some- 
times for  4 
days,  seldom 
more  than 
101  to  102  de- 
degrees. 


C  atarrhal    Slight, 
symptoms. 


Tongue. 


Throat. 


Diarrhea. 
Lymph-nodes. 


Slight  coat, 
nothing  char- 
acteristic. 

Small  puncti- 
form  red 
spots  over 
uvula  and 
palate.  Phar- 
ynx slightly 
reddened. 


Pulse. 


Albuminuria. 


Varies 
fever. 

Rare 

slight. 


with 


>  to  4  days. 
Drow  s  i  n  e  s  s 
and  catarrhal 
symptoms. 


Short  or  want- 
ing, onset  usu- 
ally sudden. 


ERYTHEMA 

INFECTIOSUM. 

Feeble.  Usu- 
ally by  direct 
contact. 


Average  6  to  14 
days. 


Very  slight 
and  of  short 
duration. 


Present  in  90  or    None. 
95  per  cent,  of 
cases. 


None. 


General  e  n  - 
largem  ent, 
especially  of 
postcerv  i  c  a  1 
nodes. 


Occasional. 

Marked  high 
curve,  lasting 
about  a  week, 
average  from 
102  to  105  de- 
grees. 


Marked. 


Tongue  coated, 
that  of  any 
fever. 

Moderate  phar- 
yngitis and 
redness  of 
mucous  mem- 
branes. 


Frequent. 

Postcerv  i  cal , 
postauricular, 
and  submax- 
illary nodes 
enlarged. 


Common. 

High  fever, 
lasting  about 
a  week,  aver- 
ages 104  to  105 
degrees. 


Absent. 


Straw  b  er  ry  , 
later  mulber- 
ry tongue. 


Uncommon. 
Little  or  none. 


None. 

Sometimes 
slightly  coat- 
ed. 


Usually    a    se-    Sometimes 
vere  angina         very       slight 
sore  throat  at 
onset. 
/ 


Varies 
fever. 


with 


and    Rare. 


Depends  on  ex- 
tent of  throat 
involvement , 
glands  at  an- 
gle of  the  jaw 
involved. 

Very  rapid. 
Common. 


Not  enlarged. 

Normal. 

None. 


1  Ruhrah  in  "  Osier's  Modern  Medicine." 


384 


DISEASES   OF  INFANTS  AND   CHILDREN. 


DIFFERENTIAL  DIAGNOSIS  OF  RUBELLA,  SCARLET  FEVER, 
MEASLES,  AND  ERYTHEMA  INFECTIOSUM— Continued. 


Eruption. 


Desquamation. 


Convalescence. 


KUBKLLA. 

Begins  on 
face,  spreads 
to  neck  and 
breast,  then  to 
arms,  legs, 
and  feet.  Is 
fading  from 
older  parts 
while  spread- 
ing to  new. 
Two  forms — 
common 
form,  morbil- 
liform, small, 
slightly  ele- 
v  a  t  e  d  pap- 
ules,  dis- 
crete,  some- 
times conflu- 
ent,more  rare- 
ly scarlatini- 
form,  lasts  2 
to  4  days  or 
less,  color 
rose-red,  but 
this  varies. 


MEASLES. 

Begins  on  face, 
spreads  grad- 
ually over  en- 
tire body.  Cov- 
ering it  by  the 
second  or 
third  day, con- 
sists of  small 
papules  a  r  - 
ranged  in 
crescentic 
groups,  these 
are  confluent 
in  places, lasts 
4  to  5  days.  Is 
deep  red,  of- 
ten purplish. 


SCARLET 
FEVER. 

Begins  on  neck 
and  chest, 
spreads  slow- 
ly over  entire 
body  —  maxi- 
mum about 
the  fourth 
day.  Does  not 
affect  lips. 
Consists  o  f 
small  punc- 
tate spots  or  a 
diffuse  blush, 
disappears  on 
pressure,  lasts 
about  a  week. 
Intense  red 
color. 


Slight 
branny. 


and    Branny. 


Rapid,  no  com- 
plications. 


Slow,  frequent 
complica- 
tions, as  pneu- 
monia. Later 
other  infec- 
tiousdiseases, 
as  tuberculo- 
sis. 


Marked  in 
flakes  and 
large  pieces. 

Slow,  compli- 
cations fre- 
quent, as  ne- 
phritis, otitis 
media,  etc. 


ERYTHEMA 
\INFECTiOSUM. 

Mrst  on  face, 
las  symmetri- 
cal rose-red 
blush,  for  the 
jmost  part 
sharply  de- 
]fined,  and  re- 
jsembles  ery- 
sipelas. It  is 
hot  to  the 
touch,  but  not 
sensitive,  and 
it  does  not 
itch.  The 
second  day  it 
spreads  to  the 
body  and  ex- 
tremities, 
small  dis- 
crete crescen- 
tic patches 
over  the  body 
and  sparingly 
on  the  inner 
and  flexor 
surfaces  of 
limbs.  Mark- 
ed map -like 
eruption  on 
outer  and  ex- 
tensor sur- 
faces. Begins 
to  fade  on 
face  in  4  or  5 
days.  Lasts 
altogether  6 
to  10  days. 
None. 


Rapid,  no  com- 
plications. 


ERYTHEMA  INFECTIOSUM.1 

Definition. — A  feebly  contagious  disease  characterized 
by  a  maculopapular,  rose-red  rash  and  an  absence  of  com- 
plications and  sequela?. 

Etiology. — Most  frequent  between  four  and  twelve  years. 
Epidemics  are  most  frequent  in  spring  and  summer.  No 
specific  organism  has  as  yet  been  described. 

1  Escherich,  1896,  named  by  Sricker,  1899;  Shaw,  American  Journal 
of  Medical  Sciences,  January,  1905. 


ACUTE  INFECTIOUS  DISEASES.  385 

Incubation. — Six  to  fourteen  days. 

Occurrence. — This  disease  has  not  been  noted  in  America 
up  to  the  present  time.  It  has  been  described  in  Germany 
and   Austria. 

Symptoms. — There  are  slight  prodromes,  as  malaise  and 
a  little  sore  throat.  These  may  be  wanting.  The  rash  ap- 
pears first  on  face,  later  on  arms,  legs,  and  trunk.  It  spreads 
downward,  involving  hands  and  feet  last  of  all.  The  rash 
is  rose-red,  macular,  raised  slightly  above  the  surface.  In 
some  places  it  is  sharply  defined,  suggesting  erysipelas ;  in 
other  places  it  shades  gradually  into  the  healthy  skin.  The 
affected  skin  is  hot  to  the  touch,  but  is  not  sensitive  and  does 
not  itch.  The  color  disappears  on  pressure,  but  quickly 
reappears.  On  the  cheeks  it  is  confluent,  on  the  body  it  is 
seen  in  discrete,  crescentic  spots,  and  on  the  extremities  it  is 
most  marked  on  the  extensor  surfaces ;  is  not  so  red  as  the 
face  and  is  more  measles-like,  having  a  sort  of  map-like 
arrangement.  It  is  evanescent,  and  may  disappear  and  reap- 
pear. It  lasts  from  six  to  ten  days,  sometimes  less,  and 
there  is  no  desquamation  and  no  subsequent  pigmentation. 
The  lymph  glands  are  not  enlarged,  and  there  are  few  or  no 
subjective  symptoms. 

Prognosis. — Good.     No  fatal  cases  have  been  reported. 

Diagnosis. — From  measles  by  absence  of  catarrhal 
symptoms  and  of  Koplik  spots.  From  scarlet  fever  by  the 
absence  of  characteristic  tongue,  constitutional  symptoms, 
and  appearance  of  rash.  From  drug  rashes  by  the  history, 
from  urticaria  by  the  absence  of  itching.  Erythema  exu- 
dativum  multiforme  begins  in  the  hands  and  feet,  becomes 
vesicular,  lasts  longer,  and  there  are  marked  constitutional 
disturbances. 

Treatment. — Symptomatic. 

VARICELLA. 
(Chicken-pox.) 
Definition. —  An   acute   infectious  disease  characterized 
by  a  typical  discrete  eruption,  slight  fever,  and  trifling  con- 
stitutional disturbances. 

25 


386  DISEASES  OF  INFANTS  AND   CHILDREN. 

Etiology. — It  is  very  contagious,  and  is  conveyed  by 
direct  contact,  by  fomites,  or  even  through  the  air  for  short 
distances.  Isolation,  to  be  effective,  must  be  in  a  separate 
building.  It  occurs  sporadically  and  in  epidemics.  Children 
are  most  often  affected,  and  susceptibility  is  very  general, 
although  adults  are  but  rarely  affected.  One  attack  confers 
immunity.  Varicella  has  no  relationship  whatever  to  small- 
pox.    No  specific  organism  has  been  described  as  yet. 

Period  of  Incubation. — This  is  usually  from  fourteen 
to  sixteen  days,  occasionally  longer. 

Symptoms. — As  a  rule  the  prodromes  are  unimportant 
or  absent  and  the  eruption  may  be  the  first  thing  noted. 
Sometimes  there  are  chilliness,  slight  fever,  and  malaise  a 
day  before  it  appears,  and  occasionally  pain  in  the  back  and 
abdomen,  vomiting,  and  other  symptoms.  The  fever  is 
highest  on  the  second  or  third  day,  usually  101°  to  102°  F. ; 
sometimes  it  is  less,  and  it  may  go  as  high  as  105°  F.  After 
a  few  days  it  disappears.  There  are  no  other  characteristic 
symptoms. 

Eruption. — This  comes  out  in  successive  crops.  It  begins 
as  a  small  papule,  slightly  raised  above  the  surface,  and  sur- 
rounded by  a  red  areola,  not  unlike  a  small  flea  bite.  This 
changes  rapidly  to  a  clear  vesicle,  which  looks  almost  like  a 
drop  of  water  on  the  top  of  the  papule.  The  vesicle  drys 
from  the  center  and  sinks  in,  causing  umbilication.  Further 
drying  reduces  it  to  a  brownish  crust.  Several  days  are 
needed  for  it  to  complete  its  course,  and  some  of  the  papules 
go  through  their  cycle  more  rapidly  than  others.  All  stages 
of  the  eruption  may  be  seen  at  one  time  on  the  body,  and 
this  is  one  of  the  most  distinguishing1  characteristics  of 
chicken-pox.  The  eruption  is  most  marked  over  the  trunk. 
On  the  exposed  surfaces  it  is  liable  to  be  infected  and  become 
pustular,  and  these  pustules  may  leave  deep  white  scars,  while 
the  ordinary  eruption  leaves  none.  Under  bandages  and 
where  there  is  irritation  from  discharges,  or  where  the  skin 
is  otherwise  irritated,  the  eruption  may  be  usually  thick, 
sometimes  even  confluent.  The  number  of  vesicles  varies 
from  ten  to   eight  hundred.     They  also  vary  in  size,   the 


ACUTE  INFECTIOUS  DISEASES.  387 

average  being  that  of  a  lentil.  Sometimes  there  is  a  pem- 
phigus-like form  of  varicella,  and  a  rare  form  is  varicella 
gangrenosa,  in  which  the  eruption  becomes  gangrenous.  This 
latter  is  usually  fatal.  The  eruption  may  also  be  noted  on 
the  mucous  membranes,  in  the  mouth,  on  the  conjunctiva,  or 
on  the  genitalia, 

Complications. — Erysipelas  may  develop,  or  there  may 
be  ordinary  pus  infections.  Adenitis  is  common  if  there  are 
many  pustules,  and  nephritis  is  occasionally  noted.  Pains 
in  the  joints  are  sometimes  met  with. 

Diagnosis. — The  course  of  the  disease,  the  eruption 
coming  out  in  crops,  the  greater  frequency  on  the  trunk,  and 
the  sparseness  of  it  on  the  hands  and  face  distinguishes  it 
from  small-pox.  There  is  usually  little  difficulty,  except  in 
differentiating  the  lighter  and  irregular  forms  of  small-pox, 
such  as  occur  after  vaccination.  The  differential  diagnosis 
from  other  conditions  usually  presents  little  difficulty.  The 
course  of  the  disease  ordinarily  makes  the  diagnosis  plain,  if 
the  appearance  of  the  eruption  does  not.  Impetigo,  urticaria 
vesiculosa,  herpes,  pemphigus,  and  some  forms  of  eczema  are 
sometimes  confused  with  it. 

Prognosis. — This  is  usually  good. 

Treatment. — Little  or  no  treatment  is  required  in  the 
average  case.  If  there  is  fever  the  child  should  be  kept  in 
bed  and  carbolized  vaseline  may  be  applied  to  relieve  the 
itching.  Cold  sponges  may  be  used  if  the  fever  is  high  or 
the  child  is  nervous.  The  child  should  be  kept  clean,  and 
the  hands  and  finger  nails  should  be  kept  clean.  If  the 
scratching  cannot  be  controlled,  the  hands  and  arms  should 
be  restrained. 

THE  FOURTH  DISEASE. 

In  1900  Clement  Dukes,  physician  to  the  school  of  Rugby, 
published  a  description  of  what  he  believed  to  be  a  disease 
not  before  described,  to  which  he  gave  the  name  of  fourth 
disease.  The  chief  difference  between  this  supposed  disease 
and  German  measles  is  in  the  rash.  It  is  very  probable  that 
the  so-called  fourth  disease  is  either  a  scarlatinal  form  of 
rubella  or  mild  scarlet  fever. 


388  DISEASES  OF  INFANTS  AND   CHILDREN. 

VACCINIA.1 

(Cow-pox ;  Vaccination.) 

Definition. — Vaccinia  is  a  disease  produced  in  men  by 
the  inoculation  with  the  virus  of  cow-pox.  It  is  character- 
ized by  a  local  pock  at  the  seat  of  inoculation,  fever,  and 
some  constitutional  disturbance.  It  affords  more  or  less  per- 
fect protection  from  small-pox.  The  virus  is  secured  from 
the  vesicles  on  the  calf  (animal  virus)  or  from  vaccinated 
persons  (humanized  lymph). 

History. — Prior  to  the  introduction  of  vaccination,  small- 
pox was  about  as  common  as  measles  is  now.  Since  vacci- 
nation, small-pox  has  diminished  very  greatly,  and  where  a 
second  vaccination  is  compulsory,  as  in  Germany,  small-pox 
has  disappeared. 

Natnre  of  Vaccinia. — This  question  is  not  yet  settled. 
The  majority  of  observers  claim  that  cow-pox  is  small-pox, 
modified  by  passage  through  the  cow.  Others,  especially 
French  writers,  insist  that  vaccinia  and  small-pox  are  sepa- 
rate diseases. 

Bacteriology. — Numerous  bacilli  and  other  forms  of 
microscopic  parasites  have  been  described.  The  question 
may  be  regarded  as  unsettled. 

Time  to  Vaccinate. — As  soon  as  the  child  begins  to 
gain  in  weight  it  may  be  vaccinated.  The  second  or  third 
month  is  usually  chosen.  If  done  before  the  fifth  month  the 
constitutional  disturbance  is  slight ;  if  done  later  there  are 
fever  and  malaise.  Vaccination  should  be  repeated  about 
the  seventh  year,  or  when  the  child  starts  to  school,  and 
again  about  puberty.  Vaccination  should  always  be  repeated 
when  small-pox  is  prevalent. 

Choice  of  I,ymph. — Calf  lymph  is  always  to  be  pre- 
ferred, as  syphilis  and  other  diseases  have  followed  the  use  of 
humanized  lymph.  Either  the  glycerinated  lymph  or  that 
dried  on  points  may  be  used.  Vaccine  virus  rapidly  loses 
its  virulence  if  kept  at  70°  F.  or  over.  It  should  be  kept 
in  a  cool  place. 

1  Edward  Jenner,  1798. 


ACUTE  INFECTIOUS  DISEASES.  389 

Technic. — The  skin  above  the  insertion  of  the  deltoid 
on  the  left  arm  is  Hsually  chosen  as  the  site.  Girls  may  be 
vaccinated  on  the  leg.  Wash  the  skin  well  with  soap  and 
water.  Stretch  slightly  and  cut  with  a  sharp  lancet  just  into 
the  skin.  The  cut  should  be  quarter  of  an  inch  long.  Rub 
in  the  virus,  allow  it  to  dry,  and  protect  for  twenty-four 
hours  with  sterilized  gauze. 

Symptoms. — The  little  primary  irritation  quickly  sub- 
sides. In  three  or  four  days  there  is  a  little  papule  with  a 
reddened  zone  about  it.  By  the  sixth  day  there  is  an  urn- 
bilicated  vesicle.  This  increases  in  size  for  a  day  or  two,  and 
by  the  tenth  day  it  is  a  pustule.  There  is  usually  considerable 
swelling  about'  the  arm,  and  the  axillary  lymph  glands  are 
enlarged.  The  pustule  gradually  dries,  and  by  the  end  of 
the  second  week  is  a  brownish  scab.  This  falls  off  in  a  week 
or  ten  days  more.  There  is  marked  leukocytosis.  There  is 
considerable  constitutional  disturbance :  fever,  headache,  and 
general  malaise.     These  are  slight  in  young  infants. 

Irregular  Vaccination. — The  pock  may  appear  earlier 
or  later  than  usual  or  may  rarely  recur  a  second  time.  There 
may  be  other  vesicles,  usually  in  the  neighborhood  of  the 
poek.     There  may  be  a  rash  over  the  body. 

Complications. — These  are  rare.  Acland  gives  the 
following  list : 

1 .  During  the  first  three  days  :  Erythema,  urticaria,  vesic- 
ular and  bulbous  eruptions,  in  vaccinated  erysipelas. 

2.  After  the  third  day  and  until  the  pock  reaches  maturity  : 
Urticaria,  lichen  urticatus,  erythema  multiforme,  accidental 
ervsipelas. 

*3.  About  the  end  of  the  first  week  :  Generalized  vaccinia, 
impetigo,  vaccinal  ulceration,  glandular  abscess,  septic  infec- 
tions, gangrene. 

4.  After  the  evolution  of  the  pocks  :  Invaccinated  diseases, 

as  svphilis. 

Treatment. — The  pustule  should  be  protected  by  a 
dressing  of  gauze  or  by  a  shield,  which  should  be  removed 
every  day  or  two  and  cleansed.  Care  should  be  taken  with 
the  shield  that  it  does  not  press  on  the  pustule  and  cause  in- 


390  DISEASES  OF  INFANTS  AND  CHILDREN. 

flammation  or  upon  the  surrounding  tissue.  If  the  pustule 
becomes  infected,  wet  dressings  with  boric  acid  frequently 
changed  will  usually  be  found  satisfactory.  If  the  child  has 
fever,  it  should  be  kept  in  bed  with  cold  sponging  used  for 
the  temperature.  Codein  and  antipyrin  may  be  used  to 
allay  nervousness  and  pain,  especially  at  night. 

PERTUSSIS. 

(Whooping-cough;  Kink  Cough.) 

Definition. — An  infectious  disease  characterized  by  ca- 
tarrh of  the  respiratory  tract,  a  paroxysmal  or  spasmodic 
cough,  usually  ending  in  a  long  sonorous  inspiration  or  whoop, 
and  this  is  frequently  accompanied  by  vomiting. 

Etiology. — The  disease  is  seen  sporadically  and  epi- 
demically and  is  endemic  in  most  large  cities.  It  is  more 
frequent  in  cold  climates  and  epidemics  are  somewhat  more 
frequent  in  winter.  The  susceptibility  is  very  general,  and 
the  majority  of  persons  have  the  disease  some  time  during 
their  life.  The  greatest  predisposition  is  from  six  months  to 
five  years,  and  over  half  the  cases  occur  during  the  first  two 
years  of  life.  The  susceptibility  decreases  as  the  individual 
grows  older. 

Period  of  Incubation. — This  is  from  one  to  two  weeks. 
One  attack  usually  protects  from  a  second.  The  disease  may 
be  transmitted  from  the  earliest  symptoms  until  late  in  the 
disease.  It  is  usually  transmitted  by  direct  contact,  and 
only  a  very  short  exposure  is  necessary  for  infection.  It 
may,  however,  be  carried  by  fomites.  If  after  exposure 
sixteen  days  pass,  and  the  disease  has  not  made  its  appear- 
ance, the  chances  are  that  it  will  not  develop. 

Pathology. — A  bacillus  has  been  described  by  Koplik, 
Czaplewski,  Wollstein,  and  others.  Another  organism  has 
been  described  by  Bordet  and  Gengou,1  which  is  found  in 
the  mucus  from  the  parts  of  the  respiratory  tract  below  the 
larynx.  It  disappears  early  in  the  disease.  There  is  more 
or  less  congestion  and  catarrhal  inflammation   of  the  larynx, 

1  British  Medical  Journal,  October  9,  1909,  p.  1062. 


ACUTE  INFECTIOUS  DISEASES.  391 

trachea,  and  bronchi,  and  severe  coughing  may  produce  em- 
physema.     Hemorrhages  and   pulmonary  complications  are 

frequent  and  are  the  usual  causes  of  death.  Coughing  also 
frequently  produces  a  small  ulceration  of  the  frenum  of  the 
tongue  in  children  who  have  cut  their  teeth. 

Symptoms. — There  are  three  stages  :  Catarrhal,  spas- 
modic, and  the  stage  of  decline. 

Catarrhal  Stage. — The  child  has  a  slight  bronchitis  which 
cannot  be  distinguished  from  an  ordinary  cold.  There  is 
often  headache,  general  malaise,  and  slight  fever.  After  one 
or  two  weeks  this  passes  into  the  spasmodic  stage.  Some 
children  whoop  almost  from  the  beginning,  others  may  not 
do  so  for  over  two  weeks,  and  some  not  at  all.  There  may 
be  occasional  paroxysms  of  coughing  during  the  catarrhal 
stage,  and  a  persistent  cough  which  is  more  frequent  at  night 
should  suggest  whooping-cough. 

Spasmodic  or  Paroxysmal  Stage. — The  fever  and  catarrhal 
symptoms  disappear,  and  the  cough  becomes  more  and  more 
paroxysmal,  and  in  nearly  all  cases  there  is  the  long  inspira- 
tion or  whoop.  The  child  usually  feels  the  paroxysm  coming 
on  and  runs  to  the  mother  or  nurse  for  support,  or  grasps 
the  nearest  object,  and,  if  there  is  nothing  near,  braces  the 
body  with  the  hands  on  the  legs  near  the  knees.  There  is  a 
severe  barking  cough  of  a  loud  metallic  character,  the  face 
becomes  reddened  and  cyanotic,  the  eyes  suffused,  and  the 
veins  of  the  neck  and  head  stand  out  prominently.  There 
is  protrusion  of  the  spoon-shaped  tongue.  After  a  series  of 
coughs  there  is  a  prolonged  whoop,  and  "finally  a  small  ball 
of  tenacious  mucus  is  expelled,  frequently  with  vomiting. 
There  are  from  four  or  five  to  thirty  or  forty  paroxysms  a 
day.  About  twenty  is  the  average.  Hemorrhage  under  the 
conjunctiva  or  from  the  nose  may  be  caused  by  a  paroxysm. 

Stage  of  Decline. — The  severity  of  the  cough  gradually 
diminishes  until  it  resembles  an  ordinary  bronchitis.  After 
excitement  and  violent  exercise  it  may  become  paroxysmal 
again  for  a  short  time,  and  the  paroxysmal  character  may  be 
added  to  any  ordinary  bronchitis  which  the  child  may  have 
during  the  next  six  months. 


392  DISEASES  OF  INFANTS  AND   CHILDREN. 

The  Blood. — There  is  a  constant  leukocytosis  which  begins 
early  before  the  paroxysmal  stage,  continues  through  it,  and 
disappears  with  it.  The  leukocyte  count  varies  from  20,000 
to  25,000,  but  may  run  as  high  as  45,000.  The  principal 
increase  is  in  the  lymphocytes.  In  doubtful  cases  the  blood 
examination  is  of  great  value  in  diagnosis. 

Duration. — The  duration  of  the  attack  is  variously 
stated,  and  differs  greatly  in  different  epidemics.  Average 
figures  are  :  Incubation,  one  week ;  catarrhal  stage,  one  to 
two  weeks  ;  paroxysmal  stage,  four  to  six  weeks ;  decline, 
two  to  three  weeks. 

Complications. — These  are  very  numerous.  Hemor- 
rhage from  the  mucous  membranes  or  into  the  organs  is  fre- 
quent. Bronchopneumonia,  acute  emphysema,  and  collapse 
of  the  lung  may  occur.  Vomiting  and  diarrhea  are  not  in- 
frequent. There  are  numerous  nervous  complications,  con- 
vulsions and  cerebral  hemorrhage  being  the  most  frequent. 
Tuberculosis  and  chronic  bronchitis  may  follow. 

Symptoms  from  drugs  are  sometimes  erroneously  attributed 
to  whooping-cough.  The  most  frequent  are  drowsiness,  or 
even  unconsciousness  from  narcotics ;  delirium,  dry  throat, 
and  mydriasis  from  belladonna;  tinnitus,  gastric  disturb- 
ances, rashes,  and  other  symptoms  from  quinin. 

Diagnosis. — History  of  exposure,  the  frequency  of  the 
cough  at  night  and  its  spasmodic  character  make  the  diagnosis 
easy.  In  doubtful  cases  the  blood  examination  is  important. 
If  the  child  does  not  have  a  paroxysm  in  the  presence  of  the 
physician,  one  may  be  brought  on  for  diagnostic  purposes  by 
introducing  a  spoon  along  the  teeth,  as  in  a  throat  examina- 
tion, and  carry  the  spoon  to  the  base  of  the  tongue  in  such  a 
manner  that  the  epiglottis  comes  into  view.  Spasmodic 
cough  may  occur  in  catarrhal  laryngitis  when  there  is  an 
elongated  uvula,  adenoids,  and  enlarged  tonsils.  Paroxysmal 
coughing  may  be  caused  by  foreign  bodies  in  the  larynx, 
trachea,  or  bronchi.  The  spasmodic  cough  of  hysteria  is  rare 
in  children.  Enlarged  tracheal  or  bronchial  glands  produce 
a  cough  much  like  whooping-cough.  Barthez  and  Sannee 
give  the  following  table  of  differential  points  : 


ACUTE  INFECTIOUS  DISEASES.  393 

WHOOPING-COUGH.  ENLARGED   GLANDS. 

1.  Contagious,  epidemic.  1.  Isolated,  not  contagious. 

2.  Three   periods,   second    paroxys-     2.  No  distinct  periods. 

mal. 

3.  Paroxysmal   cough,  with  whoop,     3.  Paroxysms  short,  frequently  with- 

vomiting,  and  viscid  expectora-  out   the  whoop,    expectoration, 

don.  or  vomiting. 

4.  Respiratory  sounds  normal.  4.  Signs   of  enlarged   glands  some- 

times present. 

5.  Respiration    normal  in    interval,     5.  Asthma  in  some  cases  alternating 

apvrexia  if  simple.  with  paroxyms.     Febrile  move- 

ments with  recrudescence  in  the 
evening,  sweats,  progressive 
wasting,  etc. 

6.  Voice  natural.  6.  Sometimes  a  change  in  voice. 

7.  Usually  acute.  7.  Chronic. 

Prognosis. — Good  in  the  better  classes,  especially  after 
the  first  year.  During  the  first  year  it  is  serious,  and  in 
overcrowded  institutions  the  outlook  is  very  bad. 

Prophylaxis. — Children  with  whooping-cough  should 
be  isolated  from  others,  and  especial  care  should  be  taken  to 
avoid  infecting  young  children  and  those  with  other  diseases. 
The  patient  is  to  be  regarded  as  a  source  of  infection  until 
the  spasmodic  stage  is  over.  ^Vhere  other  children  are  to 
use  the  same  room,  or  in  institutions,  disinfection  should  be 
used  after  the  disease. 

Treatment. — Much  can  be  done  to  make  the  course  of 
the  disease  less  severe,  but  it  is  very  doubtful  if  any  treat- 
ment has  anv  influence  in  shortening;  the  duration.  Fresh 
air  is  of  great  importance.  The  child  should  be  kept  out  of 
doors  as  much  as  possible,  if  conditions  permit,  and  the 
house,  especially  the  sleeping-room,  should  be  well  venti- 
lated. The  child  should  be  moved  from  room  to  room  where 
possible.  Protect  the  child  from  drafts  and  excitement. 
The  diet  should  be  light  and  nourishing,  and  young  children 
and  those  where  there  is  much  vomiting  should  be  put  on  a 
milk  diet.  If  one  meal  is  vomited,  a  second  should  be  given 
shortly  afterward. 

Xaojele  suggests  the  following  method  of  stopping  the 
paroxysms  :  Pull  the  jaw  forward  and  downward  in  a  man- 
ner frequently  employed   by  the  anesthetists.      This  can .  be 


394  DISEASES  OF  INFANTS  AND   CHILDREN. 

done  by  the  mother  or  nurse  if  the  child  feels  a  paroxysm 
coming  on.  A  snugly  fitting  elastic  band  applied  to  the 
abdomen  is  of  use  where  there  is  much  vomiting.  It  should 
be  made  with  a  piece  of  elastic  sewed  in  the  front,  and  should 
lace  up  the  back,  extending  from  the  pubes  well  up  on  the 
chest.  No  one  drug  should  be  given  continuously  ;  changes 
should  be  made  from  one  to  another  as  needed.  Do  not 
upset  the  child's  stomach  by  indiscriminate  drugging.  The 
following  drugs  will  be  found  useful  :  Heroin  hydrochlorid 
(tIto  t°  2V  gram)-  Belladonna  (small  doses,  increased  until 
slight  flushing  of  face  occurs  after  dose).  Antipyrin  (1  to  3 
grains).  Bromoform  (1  to  3  drops,  with  caution).  Quinin 
(1  to  5  grains).  Sodium  bromid  (1  to  5  grains).  Anti- 
septic and  sedative  sprays  are  sometimes  used,  and  inhalation 
of  vapors  and  steam  from  creosote  and  water  are  of  value  if 
there  is  much  bronchitis. 

MUMPS. 
(Epidemic  Parotitis*) 

Definition. — An  acute  infectious  disease  characterized 
by  fever  and  by  swelling  and  tenderness  of  the  salivary 
glands,  usually  of  the  parotids,  but  sometimes  of  the  sub- 
maxillary and  sublingual.  Metastases  occasionally  occur  in 
other  organs. 

Etiology. — It  is  endemic  in  large  cities,  and  occurs  in 
epidemics  and  sporadically.  Epidemics  are  apparently  un- 
influenced by  the  weather  and  climate,  and  the  sexes  are 
affected  about  equally.  Most  cases  occur  between  five  and 
fifteen  years  of  age.  Susceptibility  diminishes  after  fifteen, 
and  it  is  hot  very  common  under  five.  Almost  all  children 
are  susceptible,  but  in  any  given  epidemic  only  about  one- 
third  of  those  exposed  have  the  disease.  Infection  is  by 
direct  contact,  but  it  may  be  carried  by  fomites.  One  attack 
usually  gives  immunity,  though  second  and  even  third  attacks 
may  occur. 

Pathology. — The  parotid  gland  is  inflamed,  and  the 
principal  change   is  said  to  be  in  the  interstitial  tissue.     An 


ACUTE  INFECTIOUS  DISEASES.  395 

organism  has  been  discovered  by  Laveran  and  Catrin,  but  it 
has  not  been  definitely  proved  to  be  the  cause  of  mumps. 

Period  of  Incubation. — This  is  usually  long,  being 
from  seventeen  to  twenty-one  days,  and  is  said  to  vary  from 
three  to  twenty-five  days  or  longer. 

Symptoms. — Prodromes  may  or  may  not  be  present. 
These  consist  of  fever,  with  or  without  chill,  general  malaise, 
vertigo,  drowsiness,  vomiting,  or  diarrhea  and  epistaxis. 
There  may  also  be  sweats,  fainting  spells,  pain  in  the  ear, 
and  trismus.  The  temperature  ranges  from  101°  to  104°  F. 
It  disappears  as  the  swelling  subsides,  and  sometimes  several 
days  before.  After  an  attack  of  mumps  there  may  be 
subnormal  temperature  for  some  days.  There  is  pain  at  the 
angle  of  the  jaw  and  in  the  swollen  parotid.  One  or  both 
sides  may  be  involved,  the  glands  enlarging  rather  rapidly  for 
from  three  to  six  days,  then  remaining  stationary  for  a  day 
or  two,  and  gradually  subside.  The  subsidence  is  usually 
complete  in  two  or  three  days,  although  in  severe  cases  it 
may  be  three  weeks  or  a  month  before  it  disappears  entirely. 
Where  both  sides  are  not  affected  at  the  onset,  the  opposite 
side  is  generally  involved  in  from  one  to  four  days.  The 
swelling  is  extremely  tender  and  there  is  painful  degluti- 
tion. The  average  case  presents  a  much-rounded  swelling 
at  the  angle  of  the  jaw,  with  the  lower  end  of  the  lobe  of 
the  ear  at  its  center.  It  is  sometimes  boggy  at  first,  but 
does  not  pit  on  pressure.  Later  it  becomes  very  tense  and 
firm,  the  skin  is  stretched  and  glazed,  and  there  may  or  may 
not  be  redness.  All  grades  of  intensity  may  be  seen.  Some 
articles  of  food,  such  as  lemons,  vinegar,  etc.,  may  cause 
intense  pain.  The  saliva  may  be  increased  or  diminished. 
In  very  severe  cases  there  may  be  enormous  swelling  and 
edema  of  the  tissues,  which  may  extend  all  around  the  head 
and  neck.  The  submaxillary  and  sublingual  glands  may 
be  affected  either  after  the  parotids,  at  the  same  time,  or 
alone.  Orchitis  may  occur  in  boys,  coming  on  usually  when 
the  parotid  swelling  is  subsiding,  and  sometimes  after  it  has 
disappeared  entirely.  There  is  tender  and  painful  swelling 
of  the  gland,  lasting  three  to  five  days,  and  is  often  followed 


396  DISEASES  OF  INFANTS  AND  CHILDREN. 

by  atrophy  of  the  testicles.  Vulvovaginitis  and,  rarely,  ova- 
ritis may  occur  in  girls.  Mastitis  may  occur  in  either  sex. 
Pancreatitis  may  sometimes  occur,  and  tenderness  over  the 
pancreatic  region  is  not  uncommon.  There  may  be  con- 
junctivitis and  other  eye  complications.  Tinnitus  aurium 
occurs  in  some  cases,  and  nervous  complications  have  been 
described.  Cerebral  symptoms,  like  meningitis,  convulsions, 
facial  paralysis,  and  peripheral  neuritis,  as  well  as  arthritis, 
albuminuria,  and  nephritis,  may  be  observed. 

Diagnosis. — First  from  adenitis,  chiefly  by  palpation 
and  the  location  of  the  swelling.  Parotitis  occurring  in  the 
infectious  diseases  and  septic  infections  following  disease  or 
injury  of  the  abdominal  or  pelvic  organs  should  be  excluded. 

Prognosis. — As  a  rule,  this  is  good. 

Treatment. — Keep  the  patient  in  bed.  Give  a  saline 
purge,  and  use  hot  or  cold  applications  locally  for  the  pain. 
The  food  should  be  liquid  or  soft.  Acids  and  highly  sea- 
seasoned  foods  should  be  avoided.  The  swelling  may  be 
anointed  with  an  ointment  or  a  glycerin  application,  5  per 
cent,  guaiacol  or  belladonna  may  be  used.  In  orchitis  sus- 
pend the  gland  and  apply  lead-water  and  opium  and  guaia- 
col ointment.     Anodynes  may  be  given  if  necessary. 

DIPHTHERIA.1 

Definition. — A  specific  infectious  disease  due  to  the 
Klebs-Loffler  bacillus,  usually  characterized  by  the  forma- 
tion of  a  false  membrane  locally,  generally  on  the  tonsils, 
pharynx,  nose,  or  larynx,  and  by  constitutional  symptoms, 
chief  of  which  are  moderate  fever,  great  prostration,  and 
anemia.     It   is  a  disease  in  which  there  are  great  variations, 

1  Park  and  Thorn,  tl  Diphtheria  Antitoxin,  Results  of  the  Use  of  Re- 
fined," American  Journal  of  the  Medical  Sciences,  November,  1906,  p.  686. 
A.  Seibert,  "Diphtheria  in  Early  Life,"  Archives  of  Pediatrics,  February, 
1905,  p.  116.  Joseph  Priestley,  "Diphtheria  Outbreak,  History  of,"  Prac- 
titioner, September,  1906,  p.  372.  J.  D.  Rolleston,  "Diphtheria,  Some 
Aspects  of  the  Serum  Treatment  of,"  Practitioner,  May,  1905,  p.  660.  J.  T. 
C.  Nash,  "  Diphtheria,  Treatment  of,"  Practitioner,  April,  1905,  p.  510. 
Ker,  "Treatment  of  Diphtheria,"  Practitioner,  January,  1909,  p.  94.  Rol- 
leston, "  Diphtheritic  Paralysis,"  Practitioner,  January,  1909,  p.  110. 


ACUTE  INFECTIOUS  DISEASES,  397 

both  in  the  local  and  constitutional  manifestations.     It  may 

be  followed  by  localized  or  general  paralysis. 

Etiology. — The  Klebs-Loffler  bacillus  causes  the  for- 
mation of  the  false  membrane,  and  the  absorption  of  the  toxins 
formed  by  it  causes  the  constitutional  symptoms.  The  bacil- 
lus is  found  in  the  local  lesions,  and  sometimes  in  the  blood 
and  the  various  organs. 

The  disease  is  endemic  in  most  cities,  but  may  be  seen 
sporadically  and  in  epidemics.  The  majority  of  the  cases 
occur  in  children  between  one  and  five,  and  three-fourths  of 
the  cases  under  ten.  The  sexes  are  about  equally  affected. 
The  disease  is  most  common  in  winter,  but  may  be  seen  at 
any  time. 

Predisposing  causes  are  poor  hygiene,  poor  health  from 
other  diseases,  chronic  catarrh,  and  diseased  tonsils. 

Infection. — This  occurs  by  direct  infection  in  the  great 
majority  of  cases.  The  bacilli  may  be  carried  in  the  dis- 
charges from  the  infected  part,  in  the  sputum,  and  mucus. 
The  bacilli  may  be  harbored  in  the  throats  and  noses  of 
otherwise  healthy  people  (diphtheria  carriers),  and  these  are 
great  sources  of  the  spread  of  the  disease.  These  may  be 
persons  who  have  had  the  disease,  or  others  who  have  never 
shown  anv  symptoms  whatever.  These  carriers  can  only 
be  detected  by  bacteriologic  examination.  Xurses  who 
have  been  in  close  contact  with  it  may  transmit  the  dis- 
ease. It  may  be  carried  in  fomites.  Domestic  animals  may 
be  carriers,  and  epidemics  have  been  spread  by  milk.  The 
virulence  of  the  bacteria  exists  for  a  long  time  even  in  the 
dried  state.  Diphtheria  bacilli  exhibit  great  differences  in 
virulence,  and  there  are  great  variations  in  the  intensity  of 
different  epidemics. 

Mixed  Infections. —  Other  pathogenic  bacteria  may  be  asso- 
ciated with  the  diphtheria  bacillus,  and  help  in  causing  both 
local  and  constitutional  symptoms,  usually  greatly  intensifying 
both.  The  pus-forming  organisms,  streptococci  and  staphy- 
lococci, are  most  frequent.  Their  presence  may  usually  be 
suspected  from  certain  symptoms,  and  they  may  be  demon- 
strated by  bacteriologic  examination. 


398  DISEASES  OF  INFANTS  AND   CHILDREN. 

Pathology. — The  lesions  are  local  and  constitutional. 
The  latter  are  due  to  the  toxin  circulating  in  the  blood  and 
lymph,  and  consist  in  acute  degenerations  of  the  cells  of  the 
principal  organs  and  tissues  of  the  body.  Local  cell  changes 
may  be  noted  in  the  affected  epithelium,  in  the  cells  of  the 
liver,  heart,  kidney,  nervous  system,  and  elsewhere.  The 
changes  may  be  only  degenerations,  but  sometimes  focal 
necroses  may  occur.  Constitutional  symptoms  may  be  due 
to  other  associated  bacteria. 

The  local  changes  are  variable.  The  bacillus  may  cause 
only  a  catarrhal  inflammation  with  certain  degenerations  in 
the  epithelial  cells.  This  can  only  be  differentiated  clinically 
by  bacteriologic  examination.  The  most  frequent  lesion  is 
the  formation  of  a  false  membrane.  There  is  necrosis  and  a 
hyaline  degeneration  of  the  tissues,  fibrin  is  poured  out,  and 
this,  with  the  necrotic  tissue  and  cellular  exudate,  forms  a 
dense,  adherent  "false  membrane."  The  location  of  the 
membrane  is  usually  in  the  fauces,  about  65  per  cent.,  or  the 
fauces  and  nose,  about  15  per  cent.,  or  in  the  larynx,  about 
15  per  cent.  The  remaining  5  per  cent,  is  distributed  in  the 
nose,  mouth,  conjunctiva,  skin,  vulva,  vagina,  etc. 

Other  lesions  are  fatty  degeneration  of  the  heart,  anemia, 
enlargement  of  the  cervical  lymph-nodes,  enlargement  of  the 
spleen,  and  changes  in  the  blood-vessels,  kidneys,  and  central 
nervous  system.  Pneumonia  and  nephritis  are  frequent  com- 
plications. 

The  Incubation  Period. — This  is  usually  short  and 
varies  from  two  to  seven  days. 

Immunity. — This  varies  greatly,  and  in  cases  in  which 
antitoxin  is  used  early  is  probably  short,  as  the  immunity  is 
passively  acquired.  In  cases  where  it  is  not  used  the  im- 
munity is  more  lasting,  having  been  actively  acquired,  but 
on  this  point  there  are  great  differences  of  opinion. 

Symptoms. — These  vary  greatly,  differing  with  the 
severity  of  the  infection  and  the  location  of  the  local 
changes. 

Cases  Without  Membrane. — These  may  be  noted  especially 
during  epidemics  and  in  persons   exposed  to  the  disease. 


ACUTE  INFECTIOUS  DISEASES.  399 

The  symptoms  are  those  of  an  ordinary  coryza  or  pharyn- 
gitis, as  the  dase  may  be.  The  diagnosis  is  made  by  bacteri- 
ologic  examination,  but  an  irritating  discharge  from  the  nose, 
which  is  persistent  and  causes  excoriations,  should  always 
arouse  suspicion.  Sometimes  these  cases  persist  for  weeks, 
and  may  change  into  diphtheria  of  the  ordinary  type.  These 
catarrhal  cases  are  most  common  in  infants. 

Mild  Membranous  Cases. — In  these  the  membrane  is,  as  a 
rule,  limited  to  the  tonsil  or  near  it,  and  in  some  cases  it 
may  resemble  an  ordinary  follicular  tonsillitis.  There  is 
little  constitutional  disturbance.  The  temperature  is  usually 
about  100.5°  to  102.5°  F.,  aud  the  child  may  complain  of 
slight  pain  in  the  throat,  and  the  lymph-nodes  at  the  angle 
of  the  j  iw  are  slightly  swollen.  The  disease  starts  as  a  red- 
dened area,  which  becomes  covered  with  a  filmy  grayish- 
white  membrane,  and  this  becomes  whiter  as  it  grows  thicker. 
The  edges  are  more  or  less  sharply  outlined  and  irregular  in 
shape.  It  requires  considerable  force  to  remove  the  mem- 
brane, and  a  bleeding  surface  is  left.  The  diagnosis  is  usu- 
ally  reasonably  certain  from  the  appearance  of  the  throat, 
but  sometimes  it  can  only  be  made  by  cultures,  which  should 
be  taken  in  all  diseases  where  there  is  an  exudate.  Without 
treatment  the  membrane  usually  lasts  a  week  or  so,  but  when 
antitoxin  is  given  it  disappears  promptly. 

Severe  Cases. — The  onset  may  be  abrupt,  with  a  chill, 
vomiting,  headache,  and  high  fever,  or  it  may  be  gradual, 
beginning  with  mild  symptoms,  which  grow  progressively 
worse.  The  membrane  begins  as  above,  but  usually  spreads 
rapidly  over  the  fauces,  soft  palate,  and  uvula,  and  extends 
into  and  covers  the  pharynx,  and  often  extends  into  the  nose, 
causing  an  irritating  discharge.  Sometimes  the  progress  of 
the  membrane  is  more  slow.  As  the  membrane  gets  denser 
it  becomes  darker  in  color  and  may  take  on  a  greenish  cast. 
If  it  is  disturbed,  there  may  be  hemorrhage,  which  may 
change  the  appearance  to  a  blackish  color.  The  membrane 
may  extend  over  the  mucous  membranes  of  the  mouth, 
tongue,  and  lips,  although  this  is  rare.  The  lymph-nodes 
under  and  behind  the  jaw  swell  and  are  painful,  and  there 


400  DISEASES  OF  INFANTS  AND   CHILDREN. 

may  or  may  not  be  considerable  pain  in  the  throat.  The 
child  usually  breathes  through  the  mouth,  the  breath  has  a 
characteristic  fetid  odor,  the  tongue  is  dry  and  cracked,  and 
there  may  be  hemorrhages.  There  is  usually  considerable 
discharge  from  the  mouth  and  nose,  which  excoriates  the 
lips  and  chin. 

The  constitutional  symptoms  are  all  severe.  The  child 
shows  signs  of  marked  toxemia  and  is  prostrated,  very  much 
weakened,  has  a  rapid,  weak  pulse,  is  apathetic,  and  may 
even  become  unconscious ;  occasionally  there  is  great  irrita- 
bility. There  is  a  severe  grade  of  anemia  and  the  child  has 
a  marked  pallor,  which  may  become  ashy  or  cyanotic  as  the 
circulation  fails.  The  fever  is  irregular,  but  usually  rather 
low,  unless  there  are  other  bacteria  present.  There  is  loss 
of  appetite,  and  there  may  be  vomiting  and  diarrhea.  The 
urine  contains  albumin  and  casts. 

If  no  antitoxin  is  used  the  disease  progresses  for  about  a 
week,  and  then  after  a  day  or  two  more  begins  to  subside, 
the  membrane  shrivels,  loosens,  and  comes  away,  and  some- 
times part  of  it  seems  to  be  absorbed.  Sometimes  the  mem- 
brane and  symptoms  persist  longer.  The  constitutional 
symptoms  lessen  and  a  slow  convalescence  begins,  character- 
ized by  a  weak  heart  and  anemia.  Since  the  introduction  of 
antitoxin  the  prolonged  course  is  fortunately  not  often 
observed. 

Laryngeal  Cases. — Sometimes  the  disease  extends  into  the 
larynx,  and  this  most  frequently  happens  between  the  second 
and  fifth  day.  The  disease  may  start  in  the  larynx  in  about 
15  per  cent,  of  the  cases  and  be  limited  to  it.  In  either 
case  there  is  loss  of  voice,  a  hoarse,  barking,  croupy  cough, 
and  dyspnea.  The  symptoms  increase  steadily,  and  the  res- 
piration becomes  noisy  and  labored  and  cyanosis  becomes 
marked.  The  expression  is  anxious  and  the  child  is  very 
restless.  If  not  relieved  by  intubation,  tracheotomy,  or  the 
disappearance  of  the  membrane  due  to  the  administration  of 
large  quantities  of  antitoxin,  young  children  usually  die  inside 
of  forty-eight  hours,  in  older  ones  the  progress  is  more  slow, 
especially  in  robust  children. 


ACUTE  INFECTIOUS   DISEASES.  401 

Atypical  Forms. — There  may  be  a  catarrhal  inflamma- 
tion only,  as  n<>ted  above.  These  eases  are  seen  during  epi- 
demics and  may  be  the  means  of  spreading  the  disease,  as 
the  diagnosis  cannot  be  made  without  culture-. 

There  may  be  the  appearance  of  an  ordinary  follicular 
tonsillitis,  or  there  may  be  a  membrane  which  occurs  only  in 
spots. 

Nasal  Diphtheria. — The  usual  form  of  nasal  diphtheria 
is  secondary,  although  it  may  be  primary  ;  the  nose  is  filled 
with  the  membrane  ;  the  nasal  discharge  is  frequently  bloody 
and  may  cause  excoriations  of  the  upper  lip.  The  constitu- 
tional symptoms  are  very  severe  ;  there  are  marked  prostra- 
tion and  pallor.  This  is  probably  due  to  the  absorption  of 
toxin  by  the  numerous  nasal  lymphatics. 

A  second  form  is  the  so-called  membranous  or  fibrinous 
rhinitis,  in  which  a  thick  membrane  fills  the  nose  ;  the  Klebs- 
Loffler  bacillus  is  present.  Constitutional  symptoms  are 
absent  or  slight.  Recovery  always  follows  in  this  class  of 
cases. 

Mixed  Infections. — These  are  fairly  common,  the  strep- 
tococcus being  the  most  frequent  organism,  but  pneumococcus 
and  staphylococcus,  as  well  as  other  germs,  may  be  found. 
Locally,  the  membrane  is  extensive,  and  there  is  great  redness 
and  swelling  of  the  adjacent  tissues.  The  lymph-nodes  and 
cellular  tissue  of  the  neck  are  frequently  involved.  All  the 
constitutional  symptoms  are  severe.  Death  may  take  place 
from  septicemia,  toxemia,  involvement  of  the  larynx,  or, 
later,  from  heart  failure.  Pneumonia,  nephritis,  suppura- 
tion, and  hemorrhage  may  complicate  the  case  later. 

Complications. — Paralysis.1 — This  is  most  frequent 
from  two  to  ten  years  of  age,  and  is  less  frequent  if  antitoxin 
is  used  in  the  first  or  second  day  of  the  disease.  Some  cases 
come  on  during  the  first  week,  but  by  far  the  greatest  number 
come  on  in  the  second,  third,  and  fourth  week. 

Paralysis  of  the  palate  is  most  frequent,  of  the  eye  muscles 
next,  and  cardiac  paralysis  most  frequent  of  all.  The  cardiac, 
pharyngeal,  and  diaphragmatic  palsies  are  the  most  serious, 

1  Eolleston,  Practitioner,  January,  1910,  p.  110. 
26 


402  DISEASES  OF  INFANTS  AND   CHILDREN. 

especially  those  beginning  before  the  third  week,  and  paraly- 
sis coming  on  after  the  third  week  usually  recovers. 

Pneuniogastric  paralysis  usually  comes  on  in  the  second 
week ;  there  is  anorexia,  vomiting,  slow,  weak,  irregular 
pulse,  anemia,  slight  cyanosis,  often  some  dyspnea,  and  ab- 
dominal pain.  These  symptoms  get  worse,  and  death  usually 
takes  place  from  syncope,  especially  after  exertion.  Milder 
cases  may  be  seen  in  which  recovery  may  take  place. 

Diphtheria  in  Other  locations. — Conjunctival  Form. 
— This  may  be  primary  or  secondary,  and  usually  results  in 
the  loss  of  sight.     It  is  frequently  fatal. 

Skin. — In  severe  cases  this  may  be  seen  as  a  complication, 
but  it  may  occur  as  a  result  of  wound  infection,  and  occasion- 
ally more  or  less  chronic  skin  infections  are  seen.  They 
have  a  somewhat  characteristic  appearance,  difficult  of  de- 
scription. 

Ear. — This  may  be  seen  as  the  result  of  extension  from 
the  throat. 

Complications  and  Sequelae. — Hemorrhage  may  fol- 
low ulceration.  Most  frequently  this  is  in  the  nose  or  throat. 
Gangrene  of  the  throat  and  suppuration  of  the  lymph-nodes 
in  the  neck  may  follow  secondary  infections.  Broncho- 
pneumonia is  perhaps  the  most  common  of  all  complications. 

Albuminuria  is  present  in  all  severe  cases  and  severe 
nephritis  may  be  seen. 

Myocarditis  and  dilatation  of  the  heart  are  frequently 
seen  in  severe  cases,  and  cardiac  thrombosis  and  endocarditis 
may  also  be  met  with. 

Diphtheritic  paralysis  is  frequent,  and  is  considered  above 
and  elsewhere. 

Skin  rashes  of  various  kinds,  erythema,  urticaria,  etc., 
may  complicate  diphtheria. 

Diagnosis. — Two  things  must  be  considered  :  bacterio- 
logic  diagnosis  and  clinical  diagnosis. 

The  bacteriologic  diagnosis  is  made  by  passing  a  sterile 
cotton  swab  over  the  suspected  membrane,  and  then  drawing 
this  gently  over  a  culture  tube  of  blood  serum  agar.  This 
is  incubated  at  body  temperature  from  twelve  to  twenty-four 


ACUTE  INFECTIOUS  DISEASES.  403 

hours,  and  after  that  time  the  diphtheria  bacillus  gives  a 
characteristic  appearance  in  the  culture  and  also  in  smears 
examined  microscopically.  Often  a  diagnosis  may  he  made 
by  examining:  a  smear  made  directly  from  the  membrane, 
but  this  i>  Dot  a  very  reliable  method. 

The  presence  of  diphtheria  bacilli  in  the  mouth  does  not 
necessarily  mean  that  the  person  has  diphtheria,  but  where 
there  are  inflammations  or  membrane,  it  may  usually  safely 
be  regarded  as  the  cause  and  the  diagnosis  of  diphtheria 
made. 

A  negative  culture  does  not  necessarily  mean  that  the  dis- 
ease is  not  diphtheria,  as  the  bacillus  may  not  be  found  in 
early  laryngeal  or  late  pharyngeal  cases  ;  when  an  antiseptic- 
has  been  used  a  short  time  before  taking  the  culture ;  when 
the  culture  has  been  badly  contaminated  by  carelessness  in 
taking  it,  and  when  the  disease  is  in  a  tonsillar  crypt  or 
fossa?.  Common  sense  and  clinical  findings  should  always 
be  used  in  judging  bacteriologic  reports. 

Virulent  bacilli  may  be  found  in  the  throats  of  those  re- 
cently exposed  to  the  disease,  and  these  may  transmit  the 
disease  to  others.    These  people  are  called  diphtheria  carriers. 

Non-virulent  diphtheria  bacilli  maybe  found  in  the  throats 
of  people  who  have  not  been  so  exposed,  and  also  other 
organisms  more  or  less  closely  resembling  the  diphtheria 
bacillus.  These  people  are  not,  as  a  rule,  a  source  of  the 
disease. 

Clinical  Diagnosis, — The  majority  of  cases  can  be  told 
clinically  by  an  experienced  observer,  but  atypical  cases  and 
membranes  seen  in  the  course  of  other  infectious  diseases,  as 
scarlet  fever  and  measles,  may  require  cultures  to  determine 
their  nature.  Cases  of  streptococcus  and  staphylococcus 
sore  throat  offer  the  most  difficulty. 

Membranous  croup  is  almost  without  exception  diphtheria. 
A  membrane  in  the  throat  apart  from  scarlet  fever  is  more 
apt  to  be  diphtheria  than  anything  else. 

The  table  on  page  404  *  gives  the  chief  points  in  diagnosis 
at  a  glance. 

1  Reference  to  this  table  unfortunately  lost. 


404 


DISEASES  OE  INFANTS  AND   CHILDREN. 


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ACUTE  INFECTIOUS  DISEASES.  405 

Scarlet  Fever. — The  high  fever,  characteristic  rash,  and 
tongue,  rapid  pulse,  and  absence  of  diphtheria  bacilli  are  the 
distinguishing  features. 

Follicular  Tonsillitis.— This  is  distinguished  by  the  mem- 
brane being  limited  to  the  tonsil,  and  its  being  easily  wiped 
off  without  leaving  any  bleeding  points,  and  in  the  follicular 
form  by  the  plugs  of  cheesy  material.  The  fever  in  tonsil- 
litis is,  as  a  rule,  higher  than  in  diphtheria,  unless  the  latter 
is  complicated  by  a  secondary  infection. 

Ulcerative  tonsillitis  caused  by  Vincent's  bacillus  presents 
a  dirty,  soft,  yellowish  slough,  and  there  are  few  or  no  con- 
stitutional symptoms. 

Cultures  should  be  resorted  to  in  every  doubtful  case. 

Prognosis. — This  varies  a  great  deal,  both  in  the  inten- 
sity of  the  infection  and  as  to  how  much  and  how  early  anti- 
toxin is  used.  If  a  sufficiently  large  dose  is  given  on  the 
first  day  the  mortality  is  less  than  1  per  cent.,  is  less  than  2 
per  cent,  on  the  second  day,  less  than  4  per  cent,  on  the 
third  day,  and  about  12  per  cent,  on  the  fourth  day.  Later 
it  is  about  25  per  cent.  Cases  seen  late,  those  with  mixed 
infection,  laryngeal,  and  conjunctival  cases,  are  all  severe  and 
the  outlook  is  grave.  Death  may  be  caused  by  heart  failure, 
suffocation,  pneumonia,  nephritis,  and  occasionally  other 
causes. 

Prophylaxis. — All  doubtful  cases  should  be  managed 
like  diphtheria  until  the  diagnosis  is  fully  established.  The 
case  should  be  isolated,  and  nobody  allowed  in  the  room  ex- 
cept the  nurse  and  physician.  Municipalities  should  provide 
hospitals  to  which  the  children  of  those  unable  to  carry  out 
the  proper  isolation  could  be  removed.  There  should  be  as 
little  in  the  room  as  possible.  The  nurse  should  wear  wash 
dresses  and  change  the  dress  to  go  out.  She  should  keep  her 
throat  sprayed  with  some  antiseptic  solution  and  should  be 
immunized.  The  physician  should  wear  a  gown  or  long  coat 
and  thoroughly  disinfect  his  hands.  Everything  that  goes 
into  the  room  should  be  disinfected — dishes  by  boiling,  clothes, 
towels,  and  bedding  by  placing  in  carbolic  solution  1  :  40  to 
1  :  20  and  boiled  later.    Unpainted  wood  work  and  furniture 


406  DISEASES  OF  INFANTS  AND  CHILDREN. 

should  be  washed  daily  with  1  :  3000  bichlorid  solution  and 
painted  surfaces  with  1  :  40  carbolic  acid  solution.  Cultures 
should  be  taken  from  the  throat  of  the  patient  and  nurse 
before  quarantine  is  raised.  The  nurse  and  anyone  who  has 
been  exposed  to  the  disease  should  be  immunized  by  inject- 
ing 1000  units  of  antitoxin  or  500  in  case  of  young  infants. 
Where  expense  is  an  object,  500  units  may  be  used,  although 
this  amount  occasionally  fails  to  give  immunity.  The  im- 
munity lasts  from  one  month  to  six  weeks. 

Treatment. — Antitoxin  should  be  administered  at  once. 
It  is  best  injected  under  the  skin  of  the  abdomen.  Five 
thousand  units  should  be  given  as  the  initial  dose,  and  this 
should  be  repeated  in  six  hours  if  the  progress  of  the  mem- 
brane is  not  checked,  and  it  does  not  tend  to  shrivel  up  or 
become  broken  and  granular  looking.  In  very  severe  cases, 
those  seen  late  and  in  laryngeal  cases,  10,000  units  may  be 
given  as  the  initial  dose.  Where  expense  is  an  object,  3000 
units  may  be  used  as  the  initial  dose  in  mild  cases  and  2000 
in  young  infants.  There  are  no  bad  effects  from  antitoxin, 
except  an  occasional  urticaria  four  to  eight  days  after  its  ad- 
ministration and  occasional  joint  pains.  Very  exceptional 
individuals  are  sensitive  to  the  effects  of  serums  of  any  kind, 
but  these  need  not  be  considered  in  practice.  Antitoxin 
should  be  injected  with  aseptic  precautions. 

Local  Treatment. — The  throat  should  be  sprayed  with  mild 
antiseptic  solutions.  Peroxid  of  hydrogen  (1  to  4)  and  a 
saturated  solution  of  boric  acid  may  be  used  alternately.  The 
nose  should  be  douched  with  DobelPs  solution  or  peroxid  of 
hydrogen  (1  to  10)  four  to  six  times  daily. 

General  Treatment. — Strychnin  and  alcohol  may  be  used  as 
heart  stimulants  as  indicated.  Iron  is  always  indicated  for 
the  subsequent  anemia.  In  all  cases  where  the  heart  is  weak 
the  child  should  be  kept  quiet,  not  allowed  to  move  itself, 
and  all  struggling  with  the  child,  as  in  making  applications 
and  douching,  should  be  avoided. 

The  Treatment  of  Laryngeal  Obstruction. — If  the  diphthe- 
ritic membrane  is  in  the  larynx  there  will  be  more  or  less 
dyspnea.      If  the  dyspnea  is  urgent,  or  if  the  child  is  not 


ACUTE  INFECTIOUS  DISEASES.  407 

within  easy  reach  of  the  physician,  an  intubation  tube  should 
be  inserted.  Every  practitioner  should  learn  how  to  intu- 
bate. It  should  be  practised  on  the  cadaver  under  competent 
instruction  before  it  is  attempted  on  the  living  child.  The 
O'Dwyer  tubes  are  the  best.  The  procedure  is  as  follows  : 
The  proper-sized  tube  is  selected  by  measuring  it  on  a  gauge 
which  comes  with  the  intubating  set.  The  graduations  are 
according  to  the  age  of  the  child,  but  it  should  be  remembered 
that  a  large  child  will  take  a  larger  tube  than  the  average, 
and  a  small  one  a  smaller  tube.  The  tube  is  threaded  with 
a  stout  thread,  which  serves  to  remove  the  tube  if  it  is  inserted 
into  the  esophagus  by  mistake,  or  if  the  child  does  not  breathe 
properly  after  the  tube  is  introduced.  It  is  a  good  plan  to 
keep  all  the  tubes  threaded  with  a  single  thread,  and  when  a 
tube  is  to  be  used  it  may  be  taken  out  already  threaded  by 
pulling  the  thread  out  of  the  other  tubes.  It  frequently 
happens  that  in  an  urgent  case  time  is  lost  in  threading  the 
tube.  The  arms  of  the  child  should  be  placed  straight  along 
its  sides,  and  the  child  wrapped  in  a  blanket  so  as  to  secure 
both  arms  and  legs.  The  child  may  be  intubated  either  lying 
down  or  held  in  the  sitting  position.  All  other  things  being 
equal,  the  lying  down  position  is  to  be  preferred,  chiefly  on 
there  being  less  danger  of  heart  failure  in  advanced  cases  of 
diphtheria.  The  child  should  be  placed  on  a  low  table  or  on 
a  bed.  If  on  a  bed,  the  mattress  should  be  very  firm.  One 
person  holds  the  child's  body  still  and  a  second  assistant  holds 
the  head.  The  head  should  be  held  straight  in  the  median 
line,  and  should  be  neither  inclined  forward  nor  backward. 
If  the  sitting  posture  is  used  the  child  is  held  by  one  assistant, 
the  legs  between  the  lesrs  of  the  assistant,  while  a  second  assis- 
tant,  standing  behind,  holds  the  head.  A  mouth-gag  is  used 
to  hold  the  mouth  open.  The  tube  is  held  on  the  introductor 
in  the  right  hand,  and  the  thread  attached  to  the  tube  is  wound 
lightly  around  one  finger,  care  being  taken  not  to  get  it  twisted. 
The 'index-finger  of  the  left  hand  is  passed  into  the  mouth 
and  the  opening  of  the  larynx  accurately  located.  The  tube 
is  then  introduced,  using  the  finger  as  a  guide.  The  intro- 
ductor should  be  kept  in  the  middle  line,  and  when  the  end 


408  DISEASES  OF  INFANTS  AND   CHILDREN. 

of  the  tube  reaches  the  opening  of  the  larynx  the  handle  of  the 
introdnctor  is  raised,  and  at  the  same  time  the  tube  pressed 
gently  downward.  But  little  force  is  necessary.  The  intro- 
ductor  is  then  removed,  the  finger  in  the  mouth  holding  the 
edge  of  the  tube  to  prevent  its  being  withdrawn.  If  the  tube 
is  in  the  right  place  the  child  usually  coughs  a  few  times  to 
clear  it  of  mucus  and  the  breathing  becomes  easier,  and  in  a 
few  minutes  the  color  of  the  child  becomes  normal.  The 
position  of  the  tube  may  be  verified  by  the  finger.  If  the 
tube  is  accidentally  placed  in  the  esophagus  it  may  be  with- 
drawn by  means  of  the  thread.  As  soon  as  the  child  breathes 
easily  the  thread  may  be  removed,  and  the  child's  hands 
should  not  be  released  until  it  is.  The  mouth-gag  should  be 
introduced,  and  the  finger  used  to  hold  the  tube  in  place  lest 
it  be  withdrawn.  If  the  child  coughs  the  tube  up  shortly 
after  it  is  introduced  it  should  be  replaced,  using  a  larger  tube. 
If  it  is  coughed  up  in  two  or  three  days  after  the  free  use  of 
antitoxin  it  may  be  allowed  to  remain  out  unless  the  dyspnea 
returns.  Sometimes,  just  after  the  tube  is  introduced,  it  is 
advisable  to  give  the  child  a  teaspoonful  of  pure  whisky  to 
cause  coughing,  and  thus  clear  out  the  tube.  If  antitoxin  has 
been  used  the  tube  may  generally  be  removed  in  four  or  five 
days.  The  same  preparations  are  needed  as  for  the  intro- 
duction. The  extraction  is  rather  the  more  difficult.  The 
index-finger  of  the  left  hand  finds  the  opening  of  the  tube. 
With  this  as  a  guide,  the  extractor  is  introduced,  holding  it 
in  the  median  line.  As  soon  as  the  opening  of  the  tube  is 
reached  the  handle  of  the  extractor  is  raised,  and  this  allows 
the  end  of  the  extractor  to  enter  the  tube.  The  tube  is  grasped 
and  removed.  One  difficulty  experienced  is  trying  to  get  the 
extractor  into  the  tube  without  raising  the  handle  as  directed, 
another  is,  that  as  soon  as  the  extractor  touches  the  tube  the 
larynx  is  pulled  downward  by  the  muscles  contracting.  The 
latter  may  be  overcome  by  holding  the  larynx  down  with  the 
finger. 

The  voice  is  lost  when  the  tube  is  in,  and  only  a  whis- 
pered voice  possible ;  the  voice  returns  after  the  tube  is 
removed,  and  in  some  instances  the  return  requires  a  num- 
ber of  days. 


ACUTE  INFECTIOUS  DISEASES.  409 

In  some  instances  the  child  swallows  without  any  difficulty, 
but  in  others  it  must  learn  to  swallow  under  the  new  con- 
ditions. Semisolid  food  may  be  used,  or  the  child  may  take 
its  food  with  the  head  lower  than  the  body,  as  suggested  by 
Casselberry,  either  from  a  bottle  with  a  tube  lying  on  the 
nurse's  lap,  or,  in  older  children,  with  the  head  over  the  edge 
of  the  bed,  using  a  tube  placed  in  a  glass.  This  is  usually 
only  necessary  for  a  day  or  two. 

Tracheotomy. — If  intubation  instruments  are  not  at  hand, 
or  if  for  any  reason  an  intubation  cannot  be  done,  a  trache- 
otomy should  be  resorted  to  if  the  dyspnea  becomes  danger- 
ous.     Intubation  is  always  to  be  preferred. 

TYPHOID  FEVER.1 
(Enteric  Fever;  Typhus  Abdominalis.) 

Definition. — An  acute  infectious  disease  caused  by  the 
bacillus  typhosus,  characterized  anatomically  by  swelling  and 
ulcerations  of  the  lymph-follicles  of  the  intestine,  enlarge- 
ment of  the  spleen  and  mesenteric  lymph-nodes,  and  clinically 
by  continued  fever,  a  rose-red  eruption,  toxemia,  abdominal 
tenderness,  and  constipation  or  diarrhea,  and  often  marked 
nervous  symptoms.  The  course  and  symptoms  are  extremely 
variable. 

Etiology. — The  disease  may  be  transmitted  from  the 
mother  to  the  fetus.  Abortion  usually  results,  but  the  child 
may  be  born  at  term  suffering  with  a  general  typhoid  infec- 
tion. 

1  Morse,  Boston  Medical  and  Surgical  Journal,  February  27,  1896 ;  Ar- 
chives of  Pediatrics,  December,  1900.  Adams,  "  A  Study  of  550  Cases  of 
Typhoid  Fever  in  Children,"  American  Journal  of  Medical  Sciences,  vol. 
cxxxix.,  1910,  p.  638.  Patterson,  "  Surgical  Treatment  of  Perforation  of 
Intestines,"  American  Journal  of  Medical  Sciences,  May,  1909,  p.  660. 
Jopson  and  Gittings,  "  Intestinal  Perforation  During  Typhoid  Fever  in 
Children,"  American  Journal  of  Medical  Sciences,  vol.  cxxxviii.,  1909,  p.  625. 
Ker,  "  Typhoid  Fever,  Antisepsis  and  Asepsis  in  the  Treatment  of,"  Edin- 
burgh Medical  Journal,  July,  1906,  p.  29.  W.  J.  Butler,  "Typhoid  Fever 
in  Children,"  Journal  of  the  American  Medical  Association,  November  11, 
1905,  p.  1468.  C.  P>.  Ker,  "  Tvphoid  Fever,  Eecent  Work  on,"  Practitioner, 
December,  1906,  p.  780.  D.  L.  Edsall,  "Typhoidal  Insanity  in  Children," 
American  Journal  of  the  Medical  Sciences,  February,  1905,  p.  327. 


410  DISEASES  OF  INFANTS  AND   CHILI) HEN. 

Typhoid  fever  is  rare  in  infants  under  two  years  of  age, 
but  does  occur.  After  the  fifth  year  typhoid  is  not  uncom- 
mon. 

Infection  takes  place  usually  from  drinking  contaminated 
water  or  milk. 

Pathology. — There  have  been  but  few  autopsies,  as  the 
disease  is  rarely  fatal  in  very  young  children.  The  lesions 
are  the  same  as  in  adults,  but,  as  a  rule,  less  severe.  There 
may  be  no  ulceration  of  Peyer's  glands,  but  only  swelling, 
together  with  enlargement  of  the  spleen  and  mesenteric 
lymph  glands.  Definite  diagnosis  is  only  by  cultures  or  the 
Widal  reaction. 

Incubative  Period. — Two  to  three  weeks. 

Symptoms. — The  onset  may  be  gradual,  general  malaise, 
nervousness,  and  gradually  increasing  fever,  but  in  about 
half  the  cases  the  onset  is  sudden,  with  vomiting,  fever,  ner- 
vous symptoms,  and  prostration.  There  may  or  may  not  be 
diarrhea.  Constipation  is  frequently  seen  in  young  children, 
especially  at  the  onset. 

Temperature. — This  is  more  irregular  than  in  adults.  The 
fever  may  come  on  abruptly  or  very  slowly.  Throughout 
the  entire  disease  the  fever  may  be  irregular,  but  is  con- 
tinuous. There  may  be  hyperpyrexia.  During  convales- 
cence errors  in  diet  may  cause  fever. 

Eruption. — This  is  not  as  constant  as  in  adults.  It  con- 
sists of  the  same  rose-colored  spots,  appearing  on  the  back 
and  abdomen  about  the  tenth  day.  The  spots  last  three  or 
four  days  and  disappear ;  successive  crops  appear  for  a  week 
or  more. 

Mouth  and  Tongue. — The  mouth  is  usually  dry  and  the  lips 
dry  and  parched.  The  tongue  is  coated  with  a  white  coat 
early  in  the  disease,  and  later  this  becomes  brownish  or  yel- 
low. The  tongue  may  clear  off  and  become  glazed  and  dry. 
Fissures  of  the  tongue  and  lips  are  not  infrequent. 

Pulmonary  Symptoms. — Bronchitis  is  a  common  occurrence, 
and  it  is  usually  observed  by  the  end  of  the  first  week. 
Bronchopneumonia  and  lobar  pneumonia  are  not  so  frequent, 
but  may  be  observed.     Pleurisy  may  also  be  noted. 


ACUTE  INFECTIOUS  DISEASES.  411 

Lymph -nodes. — These  are  often  slightly  enlarged. 

Abdominal  Symptoms. — These  are  less  marked  than  in 
adults.  There  may  or  may  not  be  tenderness  and  tym- 
panites. Diarrhea  is  present  in  about  half  the  cases.  The 
spleen  is  usually  enlarged  and  easily  palpated. 

Nervous  Symptoms. — These  vary  with  the  fever  ;  there  may 
be  delirium  or  a  general  nervous  condition,  or  there  may  be 
symptoms  not  unlike  meningitis.  Mental  symptoms  are  not 
uncommon  either  during  the  course  of  the  disease  or  conva- 
lescence. 

Pulse. — This  is  rapid,  but  in  typhoid  fever  the  pulse  is 
lower  than  in  a  like  amount  of  fever  from  other  causes. 

Emaciation. — This  is  usually  marked. 

Urine. — There  is  often  a  little  albuminuria.  After  the  first 
week  Ehrlich's  diazo-reaction  is  usually  present. 

Intestinal  Hemorrhage  and  Perforation. — These  are  both 
rare  in  children,  especially  so  in  very  young  children. 

Course  and  Duration. — The  average  duration  of  the 
disease  in  childhood  is  about  two  weeks.  Many  cases  have 
fever  only  a  week  or  ten  days.  Some  cases  last  for  weeks. 
Relapses  are  not  uncommon. 

Complications  and  Sequelae.  —  Bronchitis  is  fre- 
quent. Pneumonia  is  occasionally  seen.  Suppuration  of 
the  middle  ear  or  of  the  bones  may  follow.  Meningitis 
may  also  occur. 

Diagnosis. — The  presence  of  the  Widal  agglutination 
reaction  is  the  most  positive  evidence,  and  may  be  demon- 
strated in  about  95  per  cent,  of  the  cases.  Unfortunately  it 
is  rarely  obtained  before  the  seventh  day  and  often  much 
later. 

Typhoid  bacilli  can  often  be  demonstrated  in  the  urine 
and  feces. 

A  continued  fever,  with  rose  spots  and  an  enlarged  spleen, 
is  usually  typhoid  fever  if  malaria,  tuberculosis,  and  ileo- 
colitis have  been  excluded. 

Ophthalmic  tests  for  both  typhoid  and  colon  infection1 
along  the  same  lines  as  the  conjunctival  test  in  tuberculosis 

1  Journal  of  Medical  Research,  January,  1909,  p.  95. 


412  DISEASES  OF  INFANTS  AND   CHILDREN. 

have  been  suggested,  and  a  reaction  similar  to  the  Wasser- 
mann,  Neisser-Bruck  has  also  been  used  and  is  apparently 
very  reliable.1 

The  presence  of  the  malaria  parasite  and  the  influence  of 
quinin  clear  up  the  question  of  malaria. 

General  miliary  tuberculosis  is  usually  impossible  to  dis- 
tinguish (except  by  the  Widal  reaction)  until  lung  symptoms 
appear.     The  pulse  is  more  rapid  in  tuberculosis. 

Ileocolitis  is  most  frequently  seen  in  young  children,  and 
the  bowel  symptoms  are,  as  a  rule,  more  intense  than  those 
seen  in  typhoid. 

Meningitis  may  be  difficult  to  distinguish,  as  marked  cere- 
bral symptoms  may  simulate  it  closely.  The  coma  of  typhoid 
is  not  as  complete,  the  pulse  is  not  as  slow  or  so  irregular ; 
there  is  rarely  paralysis,  and  the  abdomen  is  not  retracted. 

Prognosis. — During  the  first  year  typhoid  is  a  serious 
disease,  after  that  the  prognosis  is  much  better  than  in  adults. 
The  average  mortality  is  from  3  to  5  per  cent. 

Prophylaxis. — Everything  used  by  the  patient  should 
be  kept  separate  and  frequently  sterilized.  All  laundry  articles 
should  be  soaked  in  1:20  carbolic  acid  for  two  hours  or  more. 
Stools  and  urine  may  be  sterilized  by  mixing  them  with  a 
1  :  20  solution  of  carbolic  acid  for  six  hours  and  then  boiled. 
Blankets,  mattresses,  and  pillows  should  be  sterilized  by  steam. 

Antityphoid  vaccination  may  be  done  on  persons  about  to 
travel  in  countries  where  typhoid  is  prevalent,  or  in  those 
constantly  exposed.2 

Treatment. — Rest  in  bed,  a  liquid  diet,  consisting  largely 
of  milk,  cold  sponging  or  bathing  to  reduce  high  temperature 
and  allay  nervous  symptoms.  Water  should  be  given  at 
frequent  intervals.  Alcohol  and  strychnin  should  be  given 
as  soon  as  the  heart  flags,  but  not  until  then.  The  bowels 
should  be  moved  once  a  day  by  enema  or  occasionally  by 
calomel,  and  an  additional  dose  of  calomel  is  advisable  if 
toxic  symptoms  are  marked.  If  diarrhea  is  present,  bismuth 
and  some  form  of  opium  or  beta-naphthol  bismuth,  salicylate 
of  bismuth,  and  codein  sulphate  may  be  used.     A  mixture 

1  Progressive  Medicine.  March,  1910,  p.  188. 

2  Stone,  Jour.  Amer.  Med.  Assoc.,  October  16,  1909,  p.  1253. 


ACUTE  INFECTIOUS  DISEASES.  413 

of  all  three  of  these  is  of  value  when  the  stools  are  loose 
and  offensive. 

Tympanites  is  often  relieved  by  the  use  of  turpentine  stupes, 
and  turpentine  or  chloroform  internally.  Charcoal  mav  lessen 
it.      Injections  of  glycerin  and  water  are  often  effective. 

Hemorrhage  from  the  Bowel. — Absolute  rest,  morphin  hypo- 
dermically  to  control  the  bowel;  do  not  give  any  food  for 
twelve  hours,  but  ice  may  be  given.  An  ice-bag  or  coil 
should  be  applied  to  the  abdomen.  Turpentine  is  recom- 
mended. For  collapse,  infusions  of  salt  solution  and  stimu- 
lants hypodermically. 

Perforation  demands  immediate  operative  interference. 

Convalescence  should  be  managed  with  care.  Liquid  food 
should  be  continued  for  about  a  week  after  temperature  has 
reached  normal.  Errors  in  diet  frequently  lead  to  a  recrudes- 
cence. 

CEREBROSPINAL  FEVER.1 

(Epidemic  Cerebrospinal  Meningitis.) 

Definition. — An  infectious  disease  characterized  by  in- 
flammation of  the  brain  and  spinal  cord.  It  occurs  sporadi- 
cally and  epidemically.  Symptoms  and  course  of  the  disease 
present  great  irregularity. 

Btiology. — The  diplococcus  intracellularis  meningitidis 
of  Weichselbaum  is  constantly  associated  with  the  disease. 
Overcrowding,  overexertion,  and  exposure  seem  to  be  pre- 
disposing factors.  The  meningococcus  is  easily  killed,  and 
the  disease  is  probably  transmitted  directly  and  by  meningo- 
coccus "  carriers." 

Pathology. — In  cases  dying  early  there  is  intense  con- 
gestion of  the  meninges.  Later  there  is  a  fibrinopurulent 
exudate  between  the  dura  and  pia  mater.  In  chronic  cases 
there  is  thickening  of  the  meninges.  Pneumonia  is  a  frequent 
complication. 

1  Councilman,  Mallory,  and  Wright,  Massachusetts  State  Board  of 
Health,  1898.  J.  L.  Morse,  "  Meningitis  in  Infancy,"  Journal  of  the  Ameri- 
can Medical  Association,  June  23,  1906,  p.  1906.  Elser  and  Hontoon,  Jour- 
nal of  Medical  Research,  1909,  p.  397.  G.  C.  Robinson,  "  Meningitis,  Bac- 
teriological Findings  in  Epidemic  Cerebrospinal,"  American  Journal  of  the 
Medical  Sciences,  April,  1906,  p.  603. 


414 


DISEASES  OF  INFANTS  AND   CHILDREN. 


Fig.  139.— Cerebrospinal  meningitis.    Tache  cGrebrale  shown  on  left  thigh. 


Stage  of  Incubation.—  Unknown. 
Symptoms. — There  is  great  irregularity  in  the  course  of 
the  disease. 


Fig.  140.-Extreme  retraction  of  head  in  basilar  meningitis  (Great  Ormond  Street 
Hospital  for  Children,  London,  1901)  (Photographed  by  Dr.  Thursfield). 

Ordinary  Form. — Usually  a  sudden  onset  with  headache, 
chill,  and  vomiting.  There  are  frequently  stiffness  of  the  neck, 
photophobia,  and  dread  of  noise.  There  are  headache  and  pains 


ACUTE  INFECTIOUS  DISEASES. 


415 


in  back  and  limbs.  There  is  stiffness  of  the  muscles  and 
often  tonic  or  clonic  spasm.  There  is  restlessness,  delirium, 
or  coma.  Paralysis  of  various  muscles,  especially  of  those 
supplied  by  the  cranial  nerves,  is  common.  Optic  neuritis 
may  occur  as  a  result  of  cranial  pressure,  or  there  may  be  a 
direct  extension  of  the  inflammation. 

Skin  eruptions  are  common,  especially  herpes.     There  is 
often  a  purpuric  rash  or  there  may  be  simple  erythema,  ery- 


Fig.  141. — Kernig's  sign,  showing  the  strong  contraction  of  the  flexors  on  attempt- 
ing to  extend  the  leg  (Osier). 

thema  nodosum,  or  urticaria.  A  flush  follows  drawing  any 
object  across  the  skin  (tache  cerebrale,  Trousseau). 

The  temperature  is  extremely  variable.  It  may  be  high 
or  low.  The  pulse  is  at  first  rapid,  later  slow  and  full,  be- 
coming more  rapid  before  death.  Deep-sighing  respiration 
is  common.     Cheyne-Stokes  breathing  may  be  noted. 

In  infants  cerebrospinal  fever  usually  gives  the  clinical 
picture  of  chronic  basilar  meningitis  (see  same). 

There  is  always  a  considerable  leukocytosis. 

Unusual  Forms. — Malignant  Form. — Fulminating  or  apo- 
plectic meningitis.     A  sudden  onset,  with  chills,  headache, 


416 


DISEASES  OF  INFANTS  AND   CHILDREN. 


delirium,  or  coma,  convulsions,  fever,  slow,  weak  pulse,  and 
death  within  a  day  or  two. 

Abortive  Form. — The  disease  starts  with  symptoms  of  the 
ordinary  form,  but  rapid  recovery  takes  place  after  a  few  days. 

Intermittent  Form. — Cases  have  been  observed  with  a  fever 
resembling  malaria. 

Chronic  Form. — The  symptoms  may  persist  for  weeks  or 
even  months.     These  cases  are  usually  fatal  in  the  end. 


Fig.  142 — Anatomic  preparation  from  a  child  twenty-one  months  old,  show- 
ing location  for  lumbar  puncture  between  third  and  fourth  spinous  processes 
(Fruhwald). 


Complications. — Pneumonia,  pericarditis,  parotitis,  and 
arthritis  are  the  most  frequent.  Paralysis,  blindness,  deaf- 
ness, or  mental  deterioration  may  follow  meningitis. 

Diagnosis. — Fever,  headache,  retraction  of  the  neck, 
delirium  or  coma,  tremor  or  rigidity  of  the  muscles,  are  the 
most  important  signs.  Kernig's  sign  is  of  value.  Contrac- 
tions of  the  flexors  of  the  leg  prevent  the  full  extension  of 
the  leg  on  the  thigh.     Leichten stern's  phenomenon,  a  light- 


ACUTE  INFECTIOUS  DISEASES. 


-417 


Ding-like  contraction  of  the  muscles  of  the  entire  body 
elicited  on  striking  any  part  of  the  bony  framework  with  a 
percussion  hammer,  may  be  present.  Vincent  and  Bellot 
have  described  a  precipitin  reaction  which  is  of  value  in 
diagnosis.1 

Centrifugalize  the  cerebrospinal  fluid,  and  place  100  drops 
in  three  test-tubes.  One  is  used  as  a  control.  To  the  other 
two  a  drop  of  antimeningitis  serum  (Flexner  or  Wassermann) 
is  added,  and  all  the  tubes  placed  in  an  incubator  at  a  tem- 
perature of  from  50°  to  53°  C.  In  from  eight  to  twelve 
hours  there  is   a   clouding ;  if  the  disease  is  due  to  cerebro- 


Fig    143. — Method  of  inserting  needle  in  lumbar  puncture— child  in  lying  posture 

(.Boston). 

spinal  fever  the  control  remains  clear.  If  the  disease  is  due 
to  any  other  bacteria  or  with  cerebrospinal  from  normal  per- 
sons the  tubes  remain  clear. 

Lumbar  Puncture.2 — With  perfect  technic  this  is  harmless. 
A  small  aspirating  needle  is  introduced  into  the  spinal  canal 
and  the  fluid  then  obtained  examined  for  bacteria  and 
cells. 


1  Bulletin  Academie  de  Medecine,  vol.  lxi.,  p.  326,  and  Bulletin  Societe 
Medicate  des  Bopitaux,  1909,  p.  952. 

2S.  J.  Kopetzky,  "  Lumbar  Puncture,"  American  Journal  of  the  Medical 
Sciences,  April,  1906,  p.  61.8,     Edward  Turton,  "  Cy todiagnosis  of  Pleural 
and  Cerebrospinal  Fluids,"  Practitionef ,  April,  1905,  p.  497. 
27 


418  DISEASES  OF  INFANTS  AND  CHILDREN. 

Procedure. — Use  strictly  aseptic  precautions,  an  anesthetic 
is  rarely  necessary.  Flex  the  body,  have  it  held  firmly, 
and  introduce  the  needle  between  the  second  and  third 
or,  the  third  and  fourth  lumbar  vertebra.  A  simple 
method  is  to  choose  the  space  which  corresponds  to  a 
line  drawn  from  the  crest  of  the  ilium.  The  easiest  method 
is  to  go  through  the  median  line  and  slightly  upward. 
Another  method  is  to  introduce  the  needle  about  1  cm.  from 
the  median  line  and  point  it  slightly  upward  and  toward 
the  median  line.  The  needle  is  introduced  from  2  to  4  cm. 
The  fluid  drops  or,  if  pressure  is  great,  runs  from  the  needle. 
It  is  turbid,  occasionally  purulent  or  bloody.  A  fluid  may 
even  present  its  normal  clearness  and  meningitis  be  present. 
Cultures  should  be  made,  although  coverslip  preparations 
from  the  centrifugalized  fluid  generally  show  whatever  organ- 
ism is  present.  If  no  centrifuge  is  at  hand,  allow  the  fluid 
to  stand  undisturbed  for  a  few  hours,  when  a  film  wTill  be 
seen,  which  may  be  easily  transferred  to  a  slide,  allowed  to 
dry,  and  stain  with  the  ordinary  methods.  This  film  con- 
tains most  of  the  bacteria  and  leukocytes.  Apparently  sterile 
fluid  may  be  tested  for  tuberculosis  by  injecting  it  into  guinea- 
pigs.  The  tubercle  bacilli,  if  present,  can  generally  be 
demonstrated  if  a  number  of  specimens  are  carefully 
studied. 

Prognosis. — The  mortality  is  high.  Without  treatment 
it  averages  about  80  per  cent.  Lumbar  puncture  for  the 
relief  of  pressure  reduces  this  slightly.  With  the  use  of  the 
Flexner-Jobling  serum  the  mortality  has  been  reduced  to 
about  30  per  cent,  or  less.  Deep  coma  and  a  protracted 
course  are  both  unfavorable  signs. 

Treatment. — This  is  as  outlined  in  meningitis,  with  the 
addition  of  the  use  of  the  Flexner-Jobling  serum.  The  serum 
should  be  kept  in  a  refrigerator  until  it  is  to  be  used,  when  it 
should  be  warmed  to  the  body  temperature  before  it  is  injected. 
From  30  to  40  c.c.  are  given  at  a  dose,  injected  directly  into 
the  spinal  canal  after  the  withdrawal  of  the  cerebrospinal 
fluid  by  lumbar  puncture.  It  is  desirable,  although  it  is  not 
essential,  to  withdraw  from  the  spinal  canal  at  least  as  much 


ACUTE  INFECTIOUS  DISEASES.  419 

fluid  as  the  amount  of  serum  to  be  injected.  The  injection 
should  be  made  slowly  and  carefully,  to  avoid  the  production 
of  symptoms  due  to  increased  pressure.  The  injection  should 
be  repeated  in  twenty-four  hours,  and  three  or  four  injections 
may  be  made,  depending  upon  the  nature  and  gravity  of  the 
case.  As  much  as  120  c.c.  have  been  injected  into  the  spinal 
canal  in  four  days.  The  earlier  the  injection  the  better  the 
results.  If  the  first  fluid  obtained  by  spinal  puncture  is 
turbulent,  or  if  it  shows  Gram-negative  diplococci,  some  of 
which  are  within  the  leukocytes,  an  injection  should  be  im- 
mediately made  without  waiting;  for  the  results  of  the  culture. 
The  treatment  should  only  be  continued  where  the  4Jsease  is 
proved  to  be  cerebrospinal  fever.  A  relapse  should  be  treated 
in  the  same  manner  as  a  fresh  case. 

ANTERIOR  POLIOMYELITIS  (Heine). 

(Infantile  Spinal  Paralysis;  Acute  Wasting  Paralysis;  The  Essential 
Paralysis  of  Children.) 

Definition. — An  acute  infectious  disease  usually  attack- 
ing the  anterior  horns  of  the  spinal  cord,  but  sometimes 
affecting  the  gray  matter  in  the  medulla,  pons,  or  cerebrum. 
(The  varieties  of  the  disease  are  given  below.)  The  disease 
is  characterized  by  an  acute  onset,  with  or  without  vomiting, 
restlessness  or  apathy,  rigidity  of  the  neck  and  often  of  other 
muscles,  headache,  often  general  pain,  and,  most  striking  of 
all,  a  more  or  less  extended  paralysis  of  the  muscles,  usually 
of  the  extremities. 

Etiology. — Noguchi  has  announced  the  discovery  of  the 
organism.  It  has  been  shown  by  Flexner  and  Lewis  and 
others  that  it  may  be  transmitted  to  monkeys  by  inoculating 
them  with  emulsions  made  from  the  spinal  cord  and  also 
from  the  brain,  lymph-nodes,  salivary  glands,  mucous  mem- 
brane of  the  nasopharynx,  and  in  the  acute  stage  by  using 
the  blood  and  cerebrospinal  fluid.  Other  animals  have  not 
been  found  susceptible. 

The  inoculation  may  be  made  by  injecting  the  material 
into  the  brain,  subdurally  in  either  cranium  or  spinal  canal, 
in  or  about  the  peripheral  nerves,  into  the  general  circulation 


420  DISEASES  OF  INFANTS  AND   CHILDREN. 

and  the  anterior  chamber  of  the  eye.  It  has  also  been  caused 
by  rubbing  on  the  mucous  membrane  of  the  nasopharynx, 
with  or  without  previous  scarification,  and  by  placing  it  into 
the  trachea,  stomach,  or  intestines. 

The  virus  will  pass  through  the  finest  filters,  is  not  de- 
stroyed by  drying  or  by  cold,  but  is  injured  by  heat  (45°  to 
50°  C).  The  incubation  period  is  from  six  to  over  thirty 
days  in  monkeys,  and  doubtless  the  same  is  true  of  human 
beings. 

The  method  of  transmission  in  the  case  of  human  beings 
is  not  quite  clear.  It  is  possible  that  some  insect  is  the  car- 
rier. Some  cases  appear  to  be  by  direct  transmission,  but 
the  question  is  still  unsettled. 

The  disease  occurs  sporadically  and  in  epidemics.  It  is 
most  frequent  in  the  summer  months,  and  most  of  the  cases 
occur  during  the  first  three  years.  Boys  are  more  frequently 
affected  than  girls.  Immunity  is  conferred  by  one  attack, 
but  individuals  affected  are  liable  to  develop  nervous  dis- 
eases in  later  life.  Paralysis  in  domestic  animals  has  often 
been  noted  during  epidemics,  but  probably  there  is  no  rela- 
tion to  the  disease. 

Pathology. — There  is  congestion  and  inflammation  of 
the  gray  matter  of  the  anterior  horns  of  the  entire  cord,  and 
this  may  extend  to  the  posterior  horn,  to  the  white  matter, 
and  also  to  the  meninges.  The  medulla,  pons,  and  brain 
may  also  be  affected.  There  may  be  hemorrhage  into  the 
anterior  horns.  There  is  degeneration  of  the  nerve-fibers  of 
the  anterior  roots  and  atrophy  of  some  of  the  cells  of  the 
anterior  horns.     Later  there  is  some  sclerosis. 

Symptomatology. — Wickman  has  made  the  following 
clinical  classification  : 

1.  Spinal  Poliomyelitie  Form. — Sudden  onset,  followed  by 
paralysis. 

2.  The  Ascending  Form  (Laundry's  Paralysis). — Involve- 
ment of  respiratory  centers.  Most  fatal  cases  belong  to  this 
type. 

3.  The  Bulbar  or  Pontine  Form. — Nerves  most  often  in- 
volved  :  facial,  ocular,  hypoglossal.     May  exist  alone  or  with/ 
paralysis  of  extremities.  \_ 


ACUTE  INFECTIOUS  DISEASES. 


421 


4.  Encephalitio   or   Cerebral  Form. — May   exist  alone  or 
with  .spinal  involvement. 

5.  The  Ataxic  Form. — Much  like  Friedreich's  ataxia, 

6.  Polyneuritic  form. 

7.  Meningitie  form. 

8.  Abortive  Form. — (1)  Gen- 
eral infection.  (2)  Symptoms 
of  meningeal  irritation.  (3) 
Cases  of  much  pain,  like  in- 
fluenza. (4)  Cases  with  marked 
digestive  disturbances. 

Symptoms. — The   prodro- 
mal  symptoms   are   irritability 
and  restlessness,  or  apathy  and 
pain  in  the  spine  and  extrem- 
ities.    The  onset  becomes  def- 
inite, with   fever  ranging  from 
100°    to   106°   F.  and   lasting 
from  two  days  to  a  week.     In 
about  one-quarter  of  the  cases 
there  is  vomiting.      There  is  a 
tendency  to   sweating,  pain   on 
movement,    and    hyperesthesia. 
During  the  early  stage  there  is 
leukopenia.      The  child  is  very 
restless  and   irritable  and  com- 
plains of  pain  and  headache,  or 
may  be  delirious  and  there  may 
be  convulsions.     On  the  other 
hand,  the    child    may  be   apa- 
thetic or  pass  into  a  stupor.    There  is  usually  photophobia  and 
sluggish  pupil  reactions.   There  is  often  rigidity  of  the  neck  and 
other  muscles.     The  deep  reflexes  are  diminished  or  lost,  and 
there  is  coldness  of  the  extremities  due  to  vasomotor  changes. 
There  may  be  difficulty  in  swallowing.    The  spleen  is  enlarged. 
The  acute  symptoms  last  from  a  few  days  to  a  week. 

The  paralysis  may  appear  the  same  day  as  the  fever,  or 
during  the   "first  few  days,  and  less  frequently  during  the 


Fig.  144.  —  Anterior    poliomyelitis. 
Paralysis  of  both  legs. 


422  DISEASES  OF  INFANTS  AND   CHILDREN. 

next  two  weeks.  The  paralysis  may  involve  any  group  or 
groups  of  muscles,  but  one  leg  is  the  most  frequent,  and 
both  legs  the  next,  then  follow  in  frequency  both  arms  and 
legs,  back,  arm  and  leg  of  same  side,  etc.  The  paralysis  is 
totally  recovered  from  in  10  per  cent,  of  the  cases  in  a  few 
days  to  three  months'  time.    About  10  per  cent,  recover  par- 


Fig.  145.— Club-feet  from  infantile  paralysis. 

tially.  There  is  marked  paralysis  left  in  about  two-thirds  of 
the  cases,  and  but  little  improvement  takes  place  after  the 
third  month.  The  paralyzed  limb  is  atrophied,  the  circula- 
tion poor,  and  there  is  retarded  growth.  The  reaction  of 
degeneration  is  seen  in  all  atrophied  muscles  which  are  to  be 
permanently  affected.  The  amount  of  permanent  paralysis 
may  be  estimated  early  by  the  use  of  the  faradic  current,  as 
permanently  affected  muscles  do  not  react  at  all  after  a  week 
or  two.     Muscles  which  are  paralyzed,  but  which  may  be 


ACUTE  INFECTIOUS  DISEASES.  423 

expected  to  recover,  show  a  diminution  in  the  reaction; 
healthy  muscles  give  a  normal  reaction. 

The  ascending  form  and  the  bulbar  form  are  liable  to 
prove  fatal,  either  from  failure  oi  heart  or  respiration  or  from 
bronchopneumonia.  The  onset  is  usually  severe  in  these 
cases,  and  there  is  paralysis  of  the  facial  muscles,  as  well  as 
of  the  extremities,  with  marked  vasomotor  disturbances,  and 
of  heart  and  respiration. 

Diagnosis. — See  Wickrnan's  classification.  Pseudopa- 
ralysis, such  as  is  seen  in  rickets,  scurvy,  and  syphilis,  must 
be  excluded.  Multiple  neuritis  comes  on  more  slowly,  is 
very  painful,  and  there  is  loss  of  sensation.  Moreover,  it  is 
rare,  except  following  diphtheria.  Some  cases  resemble  cere- 
brospinal fever  closely  and  some  suggest  tuberculous  menin- 
gitis. The  diagnosis  may  be  difficult  in  either  case,  but  a 
lumbar  puncture  may  help.  There  is  usually  an  increase  in  the 
cerebrospinal  fluid  in  meningitis  with  a  cloudy  fluid  in  cerebro- 
spinal fever.  In  anterior  poliomyelitis  there  may  be  a  slight 
increase  in  the  fluid,  but  it  does  not  show  any  organisms. 

Prognosis. — This  is  bad  as  far  as  permanent  paralysis  is 
concerned,  although  some  cases  improve  and  some  get  en- 
tirely well  (see  above).  It  is  fatal  in  about  8  per  cent,  of 
the  cases,  but  this  varies  in  different  epidemics. 

Prophylaxis. — Patients  should  be  isolated  in  screened 
rooms.  Dust  should  be  suppressed  as  far  as  possible,  and  all 
objects  coming  in  immediate  contact  with  the  patient  should 
be  sterilized. 

Treatment. — Rest,  careful  feeding,  and  quiet  during  the 
acute  stage.  Hexamethylenamin  has  been  suggested  as  a 
cerebrospinal  antiseptic.  Hot  applications  and  counterirri- 
tation  over  the  spine  have  also  been  suggested,  but  are  of 
little  value.  The  throat  may  be  sprayed  with  some  antisep- 
tic solution,  as  peroxid  of  hydrogen  diluted  with  an  equal 
amount  of  water.  As  soon  as  the  pain  is  out  of  the  affected 
parts,  they  should  be  massaged  twice  daily.  Electricity  may 
be  used,  but  only  much  later.  It  acts  in  the  same  way  as 
the  massage  in  preserving  the  nutrition  of  the  muscles  while 
the  nerves  are  regenerating.  Iron  is  needed  for  the  anemia 
and  strychnin  may  be  used  later,  but  not  in  the  early  stages 


424  DISEASES  OF  INFANTS  AND   CHILDREN. 

of  the  disease.  Re-education  of  the  muscles  should  be  sys- 
tematically undertaken,  and  much  of  the  helplessness  can 
often  be  overcome  by  this  method.  Later,  orthopedic  or  other 
surgical  treatment  may  be  indicated.  The  patients  should  be 
isolated  and  the  discharges  disinfected. 

INFLUENZA. 
(La  Grippe;  Acute  Catarrhal  Fever.) 

Definition. — A  specific  infectious  disease  characterized 
by  marked  catarrhal  symptoms. 

3$tiology. — The  disease  is  endemic  in  large  cities.  It 
occurs  in  frequent  epidemics,  and  occasionally  very  wide- 
spread epidemics  occur. 

The  specific  cause  of  the  disease  is  Pfeiffer's  bacillus  in- 
fluenzae. 

Pathology. — The  disease  is  rarely  fatal  except  from 
complications.  There  are  inflammatory  changes  in  nearly 
all  the  mucous  membranes.  There  may  be  myocarditis  or 
nephritis. 

Incubation  Period.— This  is  usually  placed  at  from 
one-half  to  three  days. 

Symptoms. — There  is  a  sudden  onset,  with  high  fever. 
There  are  coryza,  pharyngitis,  bronchitis,  and  conjunctivitis. 
In  addition  there  may  be  marked  disturbance  of  the  gastro- 
intestinal tract,  with  vomiting  and  diarrhea.  In  other  cases 
nervous  symptoms  may  predominate.  These  cases  may  be 
mistaken  for  meningitis.  The  disease  lasts  from  a  few  days 
to  weeks. 

Complications. — Pneumonia,  pleurisy,  empyema,  otitis 
media,  meningitis,  and  colitis  are  the  most  frequent.  Myo- 
carditis or  endocarditis  may  be  a  serious  complication. 

Diagnosis. — Usually  easy.  The  disease  is  sometimes 
mistaken  for  meningitis. 

Prognosis. — Good  in  uncomplicated  cases. 

Treatment. — Rest  in  bed,  sponging  for  fever  and  ner- 
vousness. Antipyrin  and  codein  or  bromids  for  nervousness. 
Drugs  may  also  be  administered  to  relieve  severe  cough  or 
diarrhea  when  present. 


A  CI  rTE  TNFECTIO I 's  DISEA  SES.  425 

EPIDEMIC  PNEUMOCOCCIC  INFECTIONS. 

Definition. — A  disea.se  caused  by  the  diplococcus  pneu- 

mococcus,  occurring  in  epidemics,  with  production  of  a  catar- 
rhal inflammation,  sometimes  with  a  fibrinous  exudate. 

Etiology. — Usually  in  family  or  institution  epidemics, 
and  most  common  in  young  children  under  seven  years  of 
age.  The  epidemics  occur  usually  in  the  spring  or  fall. 
Incubation  period  two  to  seven  days. 

Symptoms. — Chilliness,  slight  fever,  and  occasional 
night  sweats  at  the  onset;  temperature  usually  from  99.5° 
to  102°  F.,  lasting  from  three  to  seven  days;  sneezing, 
lacrimation,  mucous  discharge  from  the  nose,  running  sensa- 
tion of  the  nose,  itching  of  the  eyelids,  and  slight  sore 
throat;  spasmodic  croupy  cough,  sometimes  vomiting;  there 
is  an  intense  inflammation  of  the  mucous  membranes  and  of 
the  upper  air-passages  and  of  the  eyes.  There  may  be  a 
purulent  conjunctivitis,  sometimes  corneal  ulcers,  but  little 
or  no  mental  or  physical  depression.  In  some  cases  there  is 
a  light  yellow  fibrinous  membrane  on  the  inflamed  surfaces. 
The  cough  may  persist  for  weeks  afterward. 

Diagnosis. — One  must  exclude  measles,  whooping- 
cough,  and  influenza.  From  epidemic  catarrh  the  diagnosis 
is  only  by  bacteriologic  examination,  the  presence  of  the 
pneumococcus,  and  absence  of  the  micrococcus  catarrhalis. 

Prognosis. — Good. 

Treatment. — Rest  in  bed.  Alkaline  washes  for  the 
nose  and  eyes.  Sodium  salicylate  or  aspirin  may  make  the 
patient  more  comfortable. 

TUBERCULOSIS.1 
Definition. — Tuberculosis  is  a  specific  infectious  disease 
caused  by  the  bacillus  tuberculosis  of  Koch.     It  may  be  gen- 
eral or  it  may  affect  one  or  more  organs  or  tissues  of  the  body ; 
its  clinical  characteristics  are,  therefore,  almost  innumerable. 

1  Martha  AYollstein,  "  Tuberculosis,  Congenital,"  Archives  of  Pediatrics, 
May,  1905,  p.  321.  J.  H.  Parsons,  "  Tuberculosis,  Ocular,  in  Children," 
Lancet,  November  4,  1905,  p.  1308.  J.  L.  Morse,  ''Tuberculous  Infection, 
Protection  of  Young  Infants  and  Young  Children  from,"  American  Journal 
of  the  Medical  Sciences,  October,  1906,  p.  587. 


426  DISEASES  OF  INFANTS  AND   CHILDREN. 

Etiology. — Tuberculosis  may  be  inherited  directly  from 
the  mother.  This  is  very  rare,  but  may  occur.  What  is 
more  frequent  is  an  inherited  predisposition  to  the  disease. 
A  general  predisposition  may  be  caused  by  lack  of  fresh  air, 
sunlight,  cleanliness,  and  food.  Any  disease  which  lowers 
the  resistance  of  the  body  predisposes  to  tuberculosis  ;  measles 
and  whooping-cough  may  be  mentioned  especially.  Any 
local  lesion  may  cause  a  local  predisposition.  All  ages  are 
liable  to  tuberculosis.  The  negro  when  living  in  towns  in 
crowded  quarters  seems  especially  susceptible. 

Mode  of  Infection. — The  greatest  source  of  tubercle  bacilli 
is  the  sputum  of  consumptives.  These  bacilli  in  the  dust 
are  inspired  in  the  air  breathed  and  also  taken  into  the 
mouths  of  children  from  dust  gotten  on  the  hands  in  playing 
on  the  floor.  The  former  may  cause  lesions  in  the  lung 
directly ;  the  latter  are  carried  off  by  the  lymphatics  and  are 
liable  to  cause  gland  tuberculosis,  which  may  lead  to  lesions 
elsewhere.  Tubercle  bacilli  swallowed  or  taken  in  with  the 
food,  as  in  tuberculous  milk,  may  infect  the  intestine  or  pass 
into  the  blood  directly  by  passing  through  the  intestinal  wall 
in  a  fat-droplet.  Infected  milk,  while  a  possibility,  is  not  a 
frequent  source  of  infection. 

Pathology. — Tuberculosis  most  frequently  affects  the 
bronchial  lymph  nodes,  lungs,  and  less  frequently  the  brain 
in  children  under  two  years  of  age.  After  two  years  other 
lymph  nodes,  the  intestine  and  peritoneum,  and  the  bones  are 
most  frequently  affected.  By  the  time  death  takes  place  the 
lungs  are  generally  involved.  Autopsies  on  children  dead 
from  tuberculosis  frequently  show  lesions  in  many  organs. 

There  are  in  general  two  types  of  lesions  :  scattered  gray 
miliary  tubercles  or  coalescing  yellow  tubercles  accompanied 
by  caseation.  If  the  process  is  acute  there  is  but  little  fibrous 
tissue ;  if  it  is  chronic  there  is  usually  marked  fibrosis.  There 
may  be  infection  with  pyogenic  bacteria  and  suppuration  with 
extensive  destruction  of  tissue.  The  lesion  may  be  walled 
off  with  a  zone  of  fibrous  tissue.  There  are  all  forms  and 
gradations  of  the  above.  The  more  important  forms  are 
described  on  pages  428-440. 


ACUTE  INFECTIOUS  DISEASES.  427 

Diagnosis  by  Tuberculin  Tests.1 — Tuberculin  Injec- 
tions.— These  can  only  be  used  in  fever-free  patients.  The 
temperature  should  he  taken  at  four-hour  intervals  for  the 
twenty-four  hours  preceding  the  injection.  For  infants  under 
six  months  J  mg.  and  older  infants  1  mg.  may  be  used. 
This  is  diluted  with  a  little  0.5  per  cent,  carbolic  acid  solu- 
tion and  injected  subcutaneously  or  into  the  muscles.  The 
temperature  is  now  taken  at  two-hour  intervals,  and  if  the 
reaction  is  positive  there  is  a  rise,  beginning  in  six  to  twelve 
hours  after  the  injection  and  then  falling  to  normal.  The 
temperature  varies  in  different  cases,  but  is  usually  over 
102.5°  F.  There  may  be  some  general  disturbance.  If  the 
injection  was  made  subcutaneously,  there  is  a  local  reaction 
of  swelling  and  redness. 

The  Cutaneous  Test  (  Von  Pirquefs  Test). — The  skin  of  the 
forearm  is  cleansed  with  alcohol  and  a  drop  of  pure  tuber- 
culin is  placed  on  the  skin,  and  through  it  a  few  very  super- 
ficial scarifications  are  made  with  the  point  of  a  scalpel. 
The  active  reaction  or  the  specific  normal  reaction  begins 
from  four  to  six  hours  after  the  inoculation,  and  attains  its 
maximum  in  from  twenty  to  twenty-four  hours.  The  reac- 
tion consists  of  a  redness  about  the  scarifications.  This  per- 
sists on  the  second  day,  and  shows  a  decrease  on  the  third 
or,  at  the  latest,  on  the  fourth  day. 

Conjunctival  Test  (Calmette  or  Wolff-Eisner  Test). — The 
eyes  are  first  inspected  to  see  that  the  conjunctivae  are  alike 
in  appearance  and  healthy,  and  then  one  drop  of  a  1  per 
cent,  solution  of  pure  old  tuberculin  is  dropped  into  the  left 
conjunctival  sac.  The  sac  is  so  manipulated  that  the  fluid  is 
equally  distributed.  If  the  left  eye  shows  no  reaction  in 
from  twenty  to  twenty-four  hours,  a  drop  of  a  5  per  cent, 
solution  is  instilled  into  the  right  conjunctival  sac.  If  there 
is  no  discernible  difference  in  the  two  conjunctivae  the  reac- 
tion is  negative.  Sometimes  a  slight  doubtful  redness  occurs. 
The  positive  reaction  is  a  marked  redness  of  the  conjunctivae. 
This  test  should  not  be  used  generally,  as  eyes  have  been 
injured  by  it. 

1  flamman  and  Wolman,  Archives  of  Internal  Medicine,  May,  1909c 


428  DISEASES  OF  INFANTS  AND   CHILDREN. 

Other  Tests. — There  are  other  tests,  as  the  Moro  test, 
which  consists  in  rubbing  over  a  small  spot  of  skin  a  mixture 
of  6  parts  of  old  tuberculin  with  5  parts  of  lanolin.  This 
is  followed  by  redness  and  papules  in  twenty-four  hours. 
Hamburger  uses  an  injection  of  a  minute  dose  subcutane- 
ously.  There  is  a  local  reaction  inside  of  twenty-four  hours 
in  positive  cases. 

Value  of  Tuberculin  Diagnosis. — The  injection  method  gives 
most  reliable  results,  but  cannot  be  used  where  there  is 
fever,  and  requires  considerable  care  in  observation.  The 
von  Pirquet  reaction  is  fairly  reliable  in  infants,  but  in  older 
children  it  is  often  present  when  there  is  no  evidence  of 
tuberculosis.  A  very  small  inactive  lesion  may  cause  the 
reaction,  and  an  incorrect  conclusion  may  be  drawn.  Care 
and  common  sense  should  be  used  in  drawing  conclusions 
from  tuberculin  reaction.  If  the  cutaneous  and  ophthalmic 
tests  are  done  simultaneously,  and  if  both  are  negative,  it 
means  an  absence  of  an  active  tuberculous  focus.  If  both 
are  positive,  it  points  to  an  active  focus,  and  if  one  is  posi- 
tive and  the  other  negative  the  test  is  of  no  particular  value. 

Acute  General  Miliary  Tuberculosis. 

In  this  form  there  are  miliary  tubercles  scattered  through- 
out the  body  in  the  various  organs.  The  infection  is  carried 
by  the  blood-stream.  .  The  lesions  may  be  rather  uniformly 
distributed  with  symptoms  somewhat  resembling  typhoid 
fever,  or  there  may  be  more  marked  deposits  in  certain 
organs,  as  in  the  meninges,  causing  cerebral  symptoms,  or  in 
the  lungs,  causing  pulmonary  symptoms. 

Symptoms. — The  disease  may  resemble  a  case  of  maras- 
mus ;  sooner  or  later,  however,  there  is  fever.  Respiration 
and  pulse  are  rapid.  There  may  be  digestive  disturbances. 
Lesions  can  usually  be  made  out  in  the  lungs  before  death. 
Exposure  to  tuberculosis  and  a  family  predisposition  are  both 
important  in  diagnosis.  The  disease,  if  in  older  children, 
may  resemble  typhoid  fever.  There  is  loss  of  weight  and  a 
continuous  irregular  fever.     Sooner  or  later  pulmonary,  cere- 


A  CUTE  INFECTIO  US  I)  I  si;.  1 SES.  429 

bral,  or  other  symptoms  make  their  appearance.  An  erup- 
tion, consisting  of  scattered,  discrete  papules  the  size  of  a 
pin-head,  dull  red  in  color  and  slightly  elevated,  may  be 
noted.  It  is  of  great  diagnostic  value,  cases  showing  it  always 
proving  fatal.  The  tubercle  bacillus  may  usually  be  demon- 
strated in  them. 

Diagnosis. — The  Widal  reaction  is  important  in  distin- 
guishing it  from  typhoid  fever.  Malaria  should  be  excluded 
by  blood  examination  and  quinin. 

Prognosis. — Always  bad. 

Tuberculosis  of  the  Respiratory  Organs.1 

Pathology. — There  may  be  miliary  tuberculosis  of  the 
lungs  or  tuberculous  deposits  resembling  a  bronchopneu- 
monia. Both  lungs  are  involved,  as  a  rule.  There  are  areas 
of  caseous  tubercles  which  may  be  large  and  resemble  cheese. 
This  is  sometimes  called  "cheesy  pneumonia";  suppuration 
and  breaking  down  occur  sooner  or  later.  The  bronchial 
lvmph  nodes  are  enlarged;  in  older  children  there  maybe 
a  chronic  tuberculosis  presenting  like  features  as  the  same 
disease  in  adults. 

The  pleura  is  involved  in  nearly  every  case  of  tuberculosis. 
There  may  be  an  acute  tuberculous  pleurisy  with  or  without 
effusion.     Empyema  may  result. 

Symptoms. — Tuberculous  bronchopneumonia  may  be 
seen  together  with  any  other  tuberculous  lesion  ;  it  may 
be  a  marked  feature  of  general  tuberculosis,  occur  as  a  pri- 
mary disease,  or  be  the  cause  of  death  in  other  forms  of 
tuberculosis. 

The  course  of  the  disease  varies.     If  there  are  numerous 

scattered  miliary  tubercles  the  course  of  the  disease  is  very 

rapid.     There  are  fever,  wasting,  rapid  respiration,  cough, 

1  J.  E.  Squire,  "Tuberculosis,  Pulmonary,  in  Children,"  British  Medical 
Journal,  July  21,  1906,  p.  133.  White  and  Carpenter,  "Tuberculous  Pul- 
monary Cavities  in  Infants,"  American  Journal  of  the  Medical  Sciences,  vol. 
exxxviii.,  1909,  p.  79. 


430 


DISEASES   OF  INFANTS  AND    CHILDREN 


signs  of  bronchitis,  and  later  of  bronchopneumonia.  Death 
takes  place  in  a  few  weeks. 

If  there  are  large  caseous  deposits  there  are  similar  symp- 
toms running  a  slower  course.  There  are  the  physical  signs 
of  bronchopneumonia,  with  larger  areas  of  consolidation  ;  the 
course  is  steadily  downward,  with  death  in  from  one  to  three 
or  four  months. 

There  may  be  very  chronic  cases  of  pulmonary  tuberculo- 
sis, with  small  deposits  and  few  or  no  physical  signs,  and 


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periods  of  symptoms  and  periods  of  remission.     These  cases 
are  often  called  delicate  children  with  chronic  bronchitis. 

Diagnosis. — A  history  of  tuberculosis  in  the  family  or 
of  exposure  to  the  disease  is  important.  The  irregular  fever, 
rapid  pulse,  general  downward  course,  are  all  suggestive ;  if 


ACUTE  INFECTIOUS  DISEASES. 


431 


the  sputum  can  be  obtained  ou  a  swab  immediately  after  a 
coughing  spell,  before  it  has  been  swallowed,  the  tubercle 
bacilli  may  be  demonstrated.  In  general  the  physical  signs 
do  not  differ  from  bronchopneumonia. 

Prognosis. — Always  bad,  except  in  cases  recognized 
early  in  older  children. 

Prophylaxis.1 — All  tuberculosis  patients  who  are  expec- 
torating should  use  a  special  spit-cup  and  see  that  the  sputum 
is  destroyed.     Children  should  not  live  in  close  coutact  with 


Fig.  147.— Clubbing  of  fingers  in  tuberculosis. 

a  tuberculous  patient,  and  should  never  occupy  the  same  bed. 
Where  there  is  a  family  tendency  to  tuberculosis  the  child 
should,  if  possible,  be  brought  up  in  the  country  and  in  the 
fresh  air.  The  general  health  and  strength  of  the  child  should 
be  kept  up.    A  sedentary  indoor  life  should  be  avoided. 

Treatment. — Fresh  air  both  day  and  night.     A  change 
of  climate  is  often  desirable.     Careful  feeding  is  of  especial 

1  See  Handbook  on  the  Prevention  of  Tuberculosis,  published  by  the  Charity 
Organization  Society  of  New  York. 


432  DISEASES  OF  INFANTS  AND   CHILDREN. 

value.  Raw  and  rare  meat,  milk,  and  the  whites  of  eggs 
should  be  given  in  sufficient  quantities.  The  stomach  should 
not  be  upset  by  usiDg  nauseating  drugs.  Tonics,  as  iron, 
quinin,  strychnin,  and  arsenic,  may  be  used  where  indicated. 
Cod-liver  oil  is  one  of  the  most  valuable  remedies.  Creosote, 
creosote  carbonate,  or  guaiacol  carbonate  may  also  be  used. 

Tuberculous  Bronchitis. 

This  has  been  noted  of  recent  years.  The  symptoms  are 
those  of  an  ordinary  bronchitis  with  a  few  scattered  rales. 
Later  there  are  fever,  weakness,  anemia,  sweats,  etc.,  and  the 
disease  is  frequently  followed  by  a  tuberculous  broncho- 
pneumonia. A  persistant  cough  in  an  infant  who  has  been 
exposed  to  tuberculosis  should  suggest  the  disease.  The 
diagnosis  is  by  tuberculin  and  finding  the  tubercle  bacillus. 

Tuberculous  Meningitis.1 

(Whytt's  Disease;   Acute  Hydrocephalus;  Water  on  the  Brain;   Basilar 

Meningitis.) 

Definition. — Tuberculosis  of  the  pia  mater  usually  of 
the  cerebrum,  sometimes  of  the  cord  as  well. 

Etiology. — Tuberculosis  is  almost  always  present  else- 
where in  the  body ;  most  frequently  seen  in  the  first  two 
years  of  life. 

Pathology. — Miliary  tubercles,  sometimes  tuberculous 
deposits,  together  with  an  exudate.  The  principal  lesion  is 
usually  at  the  base  of  the  brain.  The  ventricles  may  be  dis- 
tended with  fluid. 

Symptoms. — The  onset  is  almost  always  gradual.  Gen- 
eral malaise,  loss  of  appetite,  constipation,  and  headache  are 
present.  There  are  frequent  vomiting  and  slight  fever. 
There  are  more  or  less  indefinite  brain  symptoms,  which 
may  be  present  one  day  and  absent  the  next.  Then  there  is 
the  appearance  of  marked  cerebral  symptoms,  as  convulsions, 
delirium,  later  coma,  rigidity  of  the  muscles,  retraction  of  the 

1  H.  W.  Cheney,  "Meningitis,  Primary  Tuberculous,"  Journal  of  the 
American  Medical  Association,  July  8,  1905,  p.  105.     Robert  Whytt,  1768. 


ACL  "/'A'   IM'I'J  'Tin  I  \s  DJStiASEti. 


133 


Fig.  148.— Tuberculous  meningitis,  showing  strabismus  from  paralysis  of  eye 

muscles. 

neck,  and  other  symptoms  mentioned  in  meningitis.  The 
pulse  is  at  first  rapid,  then  slow,  usually  becoming  rapid 
before  death.     The  fever  is  very  irregular.    There  are  retrac- 


Fig.  149.— Tuberculous  meningitis,  showing  convulsion. 


2H 


434 


DISEASES  OF  INFANTS  AND   CHILDREN. 


tion  of  the  abdomen,  marked  constipation,  and  often  paralysis. 
The  fontanel  bulges  if  it  is  open.  There  may  be  temporary 
remissions  of  a  marked  character.  The  course  after  coma 
starts  is  usually  rapid,  death  taking  place  in  from  one  to  two 
weeks. 

In  the  last  stage  there  are  rapid  pulse,  relaxation  of  the 
muscles,  dilated  pupils,  which  do  not  respond  to  light,  deep 
coma,  and  sometimes  convulsions. 

The  course  of  tuberculous  meningitis  is  very  irregular. 

Diagnosis. — In  the  first  stage  it  cannot  be  diagnosed. 


Fig.  150.— Tuberculous  meningitis.    Note  paralysis  of  eye  muscles. 


In  the  second  stage  the  most  important  diagnostic  points  in 
the  order  of  their  frequency  are  "constipation,  drowsi- 
ness, irregular  respiration,  vomiting  without  apparent  cause, 
irregular  pulse,  convulsions,  opisthotonus,  and  fever,  which 
is  usually  slight "  (Holt).  Strabismus,  loss  of  pupil  reflexes, 
and  facial  paralysis  are  of  great  value  if  associated  with  the 
above  symptoms.  The  tubercle  bacillus  can  usually  be  found 
in  the  spinal  fluid  if  sufficient  search  is  made. 

Prognosis. — Uniformly  fatal. 

Treatment. — As  outlined  in  meningitis. 


ACUTE  INFECTIOUS  DISEASES. 


435 


Tuberculous  Adenitis. 

(Tuberculosis   of   the   External   Lymph   Nodes.) 

Etiology. — The  greatest  number  of  cases  are  seen  from 
two  to  ten  years  of  age.  Local  irritation  of  the  nodes  from 
adjacent  inflammations  may  furnish  a  suitable  soil  for  the 
tubercle  bacillus.  An  hereditary  tendency  and  a  previous 
attack  of  measles  or  whooping-cough  may  be  mentioned  as 
predisposing  causes. 

Pathology. — The    cervical    nodes  are   most   frequently 


Fig.  151.— Tuberculous  lymphadenitis  of  the  cervical  glands  (Stengel). 

affected,  the  axillary  and  inguinal  nodes  at  times ;  the 
cervical  nodes  are  usually  infected  through  the  mouth.  The 
process  involves  one  or  more  chains  of  nodes.  There  are 
rapid  cases  where  there  are  numerous  gray  tubercles,  which 
caseate  and  usually  become  infected  \vith  pus-forming  bac- 
teria and  suppurate  with  involvement  of  the  adjacent  tissue. 
All  the  affected  nodes  do  not  break  down.  There  are,  on  the 
other  hand,  chronic  cases  where  the  formation  of  connective 
tissue  is  marked  and  the  tubercles  less  numerous.     Suppura- 


436  DISEASES  OF  INFANTS  AND   CHILDREN. 

tion  is  not  so  common  in  these  cases.     All  gradations  between 
these  two  forms  may  be  met  with. 

Symptoms. — The  process  is  essentially  a  chronic  one 
There  is  enlargement  of  a  few  nodes,  with  a  little  tenderness. 
This  disappears ;  later  there  is  again  tenderness,  usually 
with  the  extension  to  other  nodes.  The  enlarged  nodes  vary 
in  size  from  a  split  pea  to  a  walnut.  There  is  a  tendency  to 
fusion  and  involvement  of  the  adjacent  tissues.  Later  there 
is  frequently  suppuration  with  breaking  down  of  the  skin. 
A  chronic  discharging  sinus  is  often  left  or  an  ugly  irregular 
scar.     About  puberty  the  process  usually  subsides. 

Tuberculosis  of  the  Bronchial  I,ymph-nodes. — 
This  may  exist  apparently  as  a  primary  lesion,  but  is  usually 
secondary  to  a  lesion  in  the  lungs. 

Etiology. — This  form  of  tuberculosis  is  met  with  in  chil- 
dren of  all  ages,  but  rarely  causes  symptoms  until  after  two 
years  of  age. 

Pathology. — As  in  tuberculous  adenitis. 

Symptoms. — There  may  or  may  not  be  general  symptoms, 
as  in  other  forms  of  tuberculosis.  The  most  striking  symp- 
toms are  the  result  of  pressure  or  irritation.  In  the  pneu- 
mogastric  or  recurrent  laryngeal  there  may  be  spasmodic 
cough,  resembling  whooping-cough  (see  same  for  differential 
diagnosis),  the  effects  of  which  do  not  entirely  subside  after 
the  paroxysm,  a  little  wheezing  remaining.  There  may  also 
be  hoarseness  and  dyspnea.  Pressure  on  the  superior  vena 
cava  results  in  cough,  dyspnea,  cyanosis  of  face,  and  some- 
times edema  of  the  face.  Sometimes  pressure  causes  diffi- 
culty in  swallowing. 

Physical  signs  are  only  present  when  the  nodes  attain  con- 
siderable size.  There  is  dulness  over  the  sternum,  and  also 
on  each  side  of  the  spine,  from  about  the  third  to  the  seventh 
vertebra?.  There  are  changes  in  the  breath  sounds,  these 
being  more  or  less  amphoric,  and  may  suggest  a  cavity. 

Diagnosis.  — Syphilis  and  Hodgkin's  disease  aifecting  the 
mediastinal  nodes  are  both  rare  in  children.  The  Rontgen 
rays  are  of  value  in  doubtful  cases. 

Prognosis. — Sudden  death  may  follow  rupture.     The  child 


ACUTE  INFECTIOUS  DISEASES.  437 

may  die  from  tuberculosis  of  the  lungs  or  elsewhere.  Some- 
times the  disease  becomes  quiescent  ;ui<l  recovery  takes  place. 
This  probably  happens  often  after  slight  involvement  that 
has  passed  unnoticed. 

Treatment. — The  same  general  measure-  as  advised  in 
tuberculous  adenitis  and  other  forms. 

Diagnosis. — This  is  usually  easy.  In  very  young  in- 
fants it  may  be  confused  with  simple  adenitis  at  the  outset. 
Hodgkin's  disease  may  be  often  distinguished  by  its  rapid 
involvement  of  other  nodes.  A  gland  may  be  removed  in 
cases  of  doubt,  or  tuberculin  tried.  The  nodes  in  Hodgkin's 
disease  frequently  become  tuberculous.  Syphilitic  adenitis  of  a 
marked  degree  is  rare,  and  yields  promptly  to  iodid  of  potassium. 

Prognosis. — With  proper  treatment  the  outlook  is  fair. 
Tuberculosis  may  develop  elsewhere. 

Treatment. — Fresh  air,  good  food,  and  a  general  build- 
ing-up treatment  is  needed ;  if  possible  a  change  to  the 
mountains  or  seashore.  Food  is  of  more  use  than  drugs,  but 
cod-liver  oil,  hypophosphites,  and  syrup  of  the  iodid  of  iron 
are  useful.  Creosote,  creosote  carbonate,  or  guaiacol  car- 
bonate may  also  be  used.  As  a  change  mix  vomica  or 
quinin  may  be  given  in  small  doses.  Iron  should  be  used 
for  the  anemia. 

Early  cases  may  have  the  entire  chain  of  nodes  removed 
by  a  radical  operation.  Iodoform  is  the  best  application 
when  there  are  sinuses.  If  a  node  suppurates  the  abscess 
should  be  opened.  The  a?-rays  are  useful  in  treating  sinuses 
and  very  chronic  cases,  as  well  as  ulcers  that  will  not  heal. 

TJB^RCULOSIS   OF   INTESTINES;    MESENTERIC    LYMPH    NODES. 

Etiology. — The  intestines  and  mesenteric  lymph  nodes 
are  involved  in  from  one-third  to  one-half  of  the  cases  of 
tuberculosis.  Infection  of  the  intestine  occurs  usually  from 
swallowed  sputum.  Primary  intestinal  tuberculosis  is  rare. 
The  mesenteric  involvement  is  frequently  but  not  always 
secondary  to  the  lesion  in  the  intestines. 

Pathology. — In   the   intestine   there  may   be   scattered 


438  DISEASES  OF  INFANTS  AND   CHILDREN 

tubercles,  or  ulcers,  or  both.  The  ulcers  are  most  frequent 
in  the  lower  end  of  the  small  bowel.  They  run  around  the 
gut,  following  the  course  of  the  vessels.  They  are  deep, 
ragged,  often  excavated  ulcers,  which  may  perforate  or,  what 
is  more  frequent,  cause  adhesions  of  the  peritoneal  surface  of 
the  intestines.  The  lymph  nodes  show  the  same  changes  as 
seen  in  the  nodes  elsewhere  in  the  body. 

Symptoms. — These  vary.  There  may  be  diarrhea,  hem- 
orrhage, abdominal  pain,  and  intestinal  indigestion.  If  the 
nodes  are  enlarged  they  may  be  felt  on  deep  palpation. 

Diagnosis. — From  the  tubercle  bacilli  in  the  stool,  or 
on  the  above  symptoms  with  tuberculosis  of  the  lungs. 

Prognosis. — This  depends  on  the  extent  and  character 
of  the  lesions,  both  in  the  intestines  and  elsewhere. 

Treatment. — As  for  tuberculosis  elsewhere.  Drugs  may 
be  given  for  the  diarrhea  and  pain. 

Tuberculous  peritonitis. 

This  is  seen  in  children  of  all  ages,  but  rather  more  fre- 
quently in  later  childhood.  It  may  be  primary  or  secondary 
to  tuberculous  deposits  elsewhere  in  the  body.  It  may  be 
acute  or  chronic. 

1.  Scattered  miliary  tubercles  may  be  found  in 
the  peritoneum  in  general  tuberculosis.  There  are 
few  or  no  symptoms  referable  to  the  abdomen. 

2.  Miliary  Tuberculosis  of  the  Peritoneum  with 
Ascites.- — In  this  form  the  entire  peritoneum  is  covered 
with  miliary  tubercles,  discrete  and  conglomerate.  There  is 
a  large  exudate  usually  serous  and  of  a  greenish  hue,  but  it 
may  be  bloody  or  purulent.  It  may  be  free  in  the  general 
peritoneal  cavity  or  it  may  become  sacculated.  It  may 
change  to  the  fibrous  or  to  the  ulcerative  form. 

Symptoms. — Gradual  onset  with  loss  of  strength  and 
weight.  There  is  usually  slight  fever,  and  later  the  abdomen 
is  distended.  There  is  slight  abdominal  discomfort  with  a 
little  pain  and  slight  tenderness.      The  disease  lasts  from  one 


ACUTE  INFECTIOUS  DISEASES.  439 

to  four  months.     Some  recover  without  treatment,  but  most 
cases  die.     "With  operation  many  of  these  cases  recover. 

3.  Ulcerative  Tuberculosis  of  the  Peritoneum. — 
This  is  analogous  to  ulcerative  phthisis  and  is  the  most  com- 
mon form.  The  tuberculous  deposits  may  bean  inch  thick  in 
places.  The  viscera  are  matted  together,  and  here  and  there 
are  sacculations  filled  with  pus.  Caseation  may  be  marked. 
Tuberculosis  is  always  present  elsewhere  in  the  body. 

4.  Fibrous  Tuberculosis  of  the  Peritoneum. — 
This  is  analogous  to  fibroid  phthisis.  The  tuberculous  de- 
posits are  largely  composed  of  fibrous  tissue,  and  there  is 
no  caseation.  There  are  numerous  adhesions  between  the 
folds  of  the  intestines.  There  may  be  more  or  less  serous 
exudate. 

Symptoms. — Gradual  onset  and  very  slow  course,  lasting 
months  or  years.  Slight,  irregular  fever,  which  may  be 
absent  at  times.  The  abdomen  enlarges  gradually,  and  there 
may  be  marked  ascites.  Symptoms  may  disappear  entirely 
and  the  patient  remain  well  for  a  time  or  indefinitely. 

Tuberculosis  of  the  Mesenteric  I/ymph  Nodes 
(Tabes  Mesmterica). — Large  irregular  masses  of  enlarged 
lymph  nodes  are  felt  in  the  abdomen.  They  lie  close  to 
the  spine,  and  may  cause  edema  of  the  legs  from  pressure 
on  the  veins.  There  is  localized  peritonitis.  The  masses 
can  usually  be  made  out  by  palpation.  These  glands  may 
also  be  affected  in  other  forms  of  tuberculosis  of  the  perito- 
neum, but  then  the  condition  cannot  be  made  out. 

Diagnosis  of  Tuberculous  Peritonitis. — Family 
history  of  tuberculosis,  tuberculosis  elsewhere  in  the  body, 
irregular  fever,  rapid  pulse,  and  progressive  loss  of  weight 
are  all  suggestive.  Chronic  ascites  with  fever  is  almost 
always  tuberculous  ;  especially  is  this  true  if  irregular  tumor 
masses  can  be  felt. 

From  the  non-tuberculous  form  of  peritonitis  diagnosis 
may  be  impossible. 

Cirrhosis  of  the  liver  is  rare  in  early  life,  and  then  there 
is  usually  a  history  of  syphilis  and  there  may  be  jaundice. 

Treatment. — General  measures  as  for  tuberculosis  else- 


440  DISEASE'S   OF  INFANTS  AND  CHILDREN. 

where.  Laparotomy  and  washing  out  of  the  abdomen  with 
salt  solution  should  be  done  in  all  cases  with  ascites,  where 
there  is  suppuration,  where  the  fluid  is  localized  to  one  spot, 
in  intestinal  obstruction,  and  in  all  doubtful  cases.  This 
should  not  be  done  in  the  non-painful  fibrous  cases  nor 
where  there  are  numerous  sacculations  in  the  ulcerative 
form. 

Tuberculosis  of  the  kidney. 

This  is  usually  a  secondary  infection  taking  place  through 
the  circulation.  Primary  tuberculosis  of  the  kidney  has 
been  reported. 

The  Symptoms  are  pain  and  tenderness  in  the  lumbar 
region,  and  there  may,  in  cases  of  enlargement  of  the  kidney, 
be  a  tumor.  There  is  great  irritability  of  the  bladder.  The 
urine  contains  pus  and  frequently  blood.  The  tubercle 
bacillus  can  usually  be  demonstrated  in  the  urine. 

The  treatment  is  surgical. 

SYPHILIS. 

Definition. — Syphilis  is  a  communicable  disease  charac- 
terized by  an  initial  lesion,  called  a  chancre,  secondary  mani- 
festations, especially  marked  on  the  skin  and  mucous  mem- 
branes, and  by  late  tertiary  symptoms  affecting  all  the  tissues 
of  the  body,  but  especially  the  bones,  nervous  system,  and 
organs  of  special  sense.  The  disease  may  be  communicated 
in  two  ways  :  by  direct  contact,  the  acquired  form,  and  by 
inheritance,  the  hereditary  form.  It  is  caused  by  the  Spiro- 
chseta  pallida  (Schaudinn). 

Acquired  syphilis. 

Etiology. — The  child  is  usually  infected  by  the  parent 
or  nurse  through  kissing  or  accidental  contact ;  by  infected 
towels,  nipples,  spoons,  and  the  like ;  occasionally  by  sexual 
contact,  and  formerly  by  vaccination  with  humanized  lymph. 

Pathology. — This  is  essentially  the  same  as  in  adults. 

Symptoms. — The  symptoms  are  much  the  same  as  in 
adults.     There  is  a  chancre  usually  on  the  lips  or  face,  fol- 


ACUTE  INFECTIOUS  DISEASES.  441 

lowed  by  the  characteristic  eruption  and  the  later  manifesta- 
tions. The  disease  is  milder  than  the  hereditary  form,  and 
the  child  may  have  reasonably  good  health  in  spite  of  the 
disease.  The  tertiary  symptoms  come  on  in  from  three  to 
an  indefinite  number  of  years  later. 

Diagnosis. — Unless  the  chancre  is  seen  it  may  be  mis- 
taken for  hereditary  syphilis. 

Prognosis. — Good.  Fournier  reports  42  cases  with  but 
1  death. 

Treatment. — As  in  hereditary  syphilis. 

Hereditary  or  congenital  syphilis.1 

Etiology. — Syphilis  may  be  inherited  from  either  the 
father  or  mother  alone,  or  from  both.  The  more  recent  the 
disease  in  the  father  the  more  liable  it  is  to  be  transmitted. 
The  fetus  may  be  infected  by  the  father,  and  it  is  possible 
for  the  mother  to  remain  uninfected.  In  this  case  she 
acquires  immunity  (Colics'  law).  An  infant  with  hereditary 
syphilis  is  capable  of  transmitting  the  disease  to  others,  but 
probably  not  as  great  a  source  of  danger  as  an  infant  with 
the  acquired  form. 

Pathology. — The  fetus  is  liable  to  die  before  the  eighth 

month  and  miscarriage  result.      There  are  changes  in  the 

bones  (epiphysitis)  and  glands  in  these  cases.      There  may  be 

papular  or  bullous  skin  eruptions  at  the  time  of  birth.     The 

lungs  may  show  whitish  areas  of  consolidation — the  so-called 

"  white  pneumonia."     The  liver  may  show  cirrhotic  changes 

or  marked  infiltration  with  small  round  cells.      The  spleen  is 

usually  enlarged.     There  may  be  endarteritis.     The    heart 

may  show  myocardial  changes  and  endocarditis.     The  mucous 

membranes  show  inflammatory  changes.     The  bone  lesions 

are  marked.     There  is  usually  an  epiphysitis  with  irregular 

calcification  ;  later  there  may  be  necrosis  and  suppuration. 

The  skin  may  be  of  a  greenish-yellow  color,  the  nose  is  broad 

and  retracted,  and  there  may  be  a  purulent  discharge  from 

the  nose  and  ears. 

1  Saxe,  "  Syphilis,  Diagnosis  of  Hereditary,  in  School  Child,"  Archives 
of  Pediatrics,  December,  1906,  p.  916. 


442 


DISEASES  OF  INFANTS  AND   CHILDREN. 


Gummata  are  rare  under  two  years  of  age.  Later  they 
are  not  uncommon. 

Symptoms. — A  dead  fetus  should  always  suggest  syphilis, 
especially  where  several  have  been  born  dead. 

The  symptoms  may  be  present  at  birth,  or  come  on  any 
time  after  that ;  usually,  however,  within  eight  weeks.  In 
most  cases  the  symptoms  appear  in  the  second,  third,  or 
fourth  weeks.  Sometimes  symptoms  are  not  noted  until 
years  later.  (See  Late  Hereditary  Syphilis.)  The  earlier  the 
symptoms  appear  the  more  severe  the  disease. 

At  birth  there  may  be  bullous  and  macular  eruptions,, 


fiiO 


Fig.  152.— Syphilitic  dactylitis  (Chapin). 

The  most  marked  symptoms  of  hereditary  syphilis  are 
wasting  and  marasmus,  coryza  (snuffles),  a  hoarse  cry  due  to 
laryngitis,  pharyngitis,  and  facial  expression  like  that  of  an 
old  man,  a  muddy,  discolored  skin,  fissures  about  the  mouth 
and  anus,  mucous  patches  on  the  mucous  membranes  and 
adjacent  skin,  claw-shaped  or  otherwise  misshapen  or  mal- 
formed nails,  and  there  may  be  great  weakness  of  the  muscles, 
suggesting  actual  paralysis,  and  a  characteristic  eruption. 
The  hair  may  fall  out,  there  may  be  baldness,  either  general 
or  in  spots,  or  there  may  be  unusually  thick  long  hair,  either 
over  the  entire  scalp  or  in  spots.  There  may  be  thickening 
of  the  eyelids  and  scanty  eyelashes. 

The  eruption  comes  on  as  a  roseola  (diffuse  blush)  or 
macules.     These  macules  are  small,   dark   red,   copper-col- 


ACUTE  INFECTIOUS  DISEASES. 


443 


Fig.  153. —Late  congenital  syphilis. 


Fig.  154.— Late  congenital  syphilis. 


ored  spots  occurring  over  the  body,  including  the  palms  of 
the  hands  and  the  soles  of  the  feet.     There  may  be  scaling 


444 


DISEASES  OF  INFANTS  AND   CHILDREN. 


of  the  skin.     The  eruption  should   be  looked  for  especially 

about  the  eyebrows,  the  lips  and  chin,  about  the  anus  and 
genitalia,  and  on  the  thighs.  There  develop  later  papules 
and  pustules,  paronychia,  and  moist  surfaces  about  the  lips, 
anus,  and  where  the  folds  of  the  skin  come  together.  Condyl- 
omata about  the  anus  are  not  uncommon.     There  is  a  fcend- 


Fig.  155. — Congenital  syphilis,  same  as  Fig.  153  after  treatment. 

ency  to  hemorrhage,  which  in  itself  is  suggestive.  General 
debility  and  wasting,  especially  when  improvement  takes 
place  under  antisyphilitic  treatment,  is  a  point  of  value. 

These  symptoms  may  be  present  in  various  combinations 
and  some  may  be  absent.  The  clinical  picture  is  much 
changed  by  treatment. 


Acrri:  infectious  diseases. 


115 


MaenosiS.— Usually  easy  on  the  above  feature..  Other 
•l-iii  diseases  are  frequently  called  syphilis.  Rapid  response 
£^£ Si  sometime, "of  value.  In  doubtful  cases  the 
S££  can  he  settled  by  testing  for  the  Wassermann  reac- 
tion.1    The  test  should    be  made  by  an  experienced  observer 

to  he  reliable.  r        o 

Prognosis.— Bad.      A    very    large    percentage    die.     Seme 

authors  give  70  to  80  per  cent,  mortality 

Treatment—Mercury  is  the  specific.     It  may  he  admmis- 


Fig.  156-Syphilitic  inflammation  of  hand. 


tered  by  inunction,  using  the  ointment  or  the  oleate  or  va*> 
len  meVcurv  ;  but  inunctions  should  not  ordmardy  be  used 
I l\Z  young  infants  or  when  the  skin  is  tender  or  broken. 
Inter/ally  it  may  be  given  in  the  form  of  calomel   £  *»  IT 
gr.  three  or   four  times  daily,  mercury   and  chalk  n.   1  ^ 
doses,  or  the  bichlorid  in  doses  of  from  ^  to  ^  gr.      ^ 
protiodid   may  be  used  in  doses  of  from  i  to  TT Jg 
here  is  diarrhea,  opium  or  codem  may  be  used  in  ad» 
Mercury  should  be  given  for  a  year,  wnh   occasional  >^k 
in  the  treatment,  giving  tonics,  as  iron  (syrup  of  ^  he  10 did) 
or  cod-liver  oil.      If  symptoms  pers.st,  it  should  be  used 
>  Fox,  Medical  Record,  March  13,  1909,  p.  421. 


446 


DISEASES  OF  INFANTS  AND   CHILDREN. 


longer 


Iodid  of  potassium  should  then  be  given  with  or 
without  mercury,  and  it  should  be  given  subsequently  for 
any  tertiary  symptoms. 

When  there  is  a  general  eruption,  bichlorid  baths  may  be 
used.  Fissures  may  be  dusted  with  calomel  or  carefully 
touched  with  1  per  cent,  bichlorid  solution.  Condylomata 
should  be  washed  with  a  1  or  2  per  cent,  salt  solution  and 
then  dusted  with  calomel.  Persistent  onychia  may  have 
mercurial  plaster  applied.     For  snuffles  a  powder  of  1  part 


Fig.  157.— Syphilitic  dactylitis. 

calomel  and  20  parts  sugar  may  be  insufflated,  or  an  oint- 
ment of  yellow  oxid,  gr.  j  to  3J,  may  be  used  in  the  nose,  or 
the  white  precipitate  ointment  1  part  and  petrolatum  3  parts 
may  be  used. 

Injections  are  perhaps  best  not  used  in  infants,  although 
the  method  has  some  warm  advocates.  They  may  be  used 
in  severe  or  malignant  cases,  and  where  there  are  severe  vis- 
ceral lesions  or  intracranial  complications. 

Salvarsan  may  be  given  in  two  or  more  injections  not  less 
than  a  week  apart.  The  mercurial  treatment  may  be  used 
coincidently  or  afterward  if  desired.  After  five  years  of 
age  it  is  best  given,  as  in  adults,  intravenously,  in  doses  of 


ACUTE  INFECTIOUS  DISEASES. 


447 


0.1  gram  to  0.2  gram.  In  younger  children  this  is  difficult, 
and  injections  into  the  muscles,  in  doses  of  from  0.03  to  0.05 
to  0.1  gram,  according  to  age  and  size.  The  drug  may  be 
suspended  in  ben/oinol  or  any  bland  oil  or  in  water.  The 
injection  should  be  made  into  the  buttocks  in  such  a  manner 
as  not  to  avoid  the  neighborhood  of  the  sciatic  nerve  and  the 
larger  vessels.  Two  sites  are  recommended  :  first,  a  point 
midway  between  the  anterior  superior  spine  and  the  top  of 
the  internatal  cleft,  the  needle  to  go  forward,  outward,  and 
slightly  upward.  In  thin  children  there  is  not  much  tissue 
at  this  point ;  second,  draw  a  line  from  the  top  of  the  great 


S'eiaTic  Tieri/e 


Fig.  157a.— Sites  for  intramuscular  injection,  showing  location  where  to  avoid 

the  sciatic  nerve. 

trochanter  to  the  top  of  the  internatal  cleft.  Inject  at  the 
junction  of  the  inner  and  middle  thirds.  This  has  the  ob- 
jection of  being  near  the  gluteal  vessels.  JNeosalvarsan  may 
be  used.  It  has  the  advantage  of  being  soluble  in  water, 
but  the  disadvantage  of  being  more  unstable,  and  it  must  be 
used  as  soon  as  prepared.  0.9  gram  of  neosalvarsan  is  equal 
to  0.6  gram  salvarsan.  0.05  gram  of  salvarsan  may  be  dis- 
solved in  5  c.c.  water  and  injected  intravenously.  The  dose 
may  be  repeated  in  two  weeks  and  in  one  or  two  months  until 
Wassermann  reaction  is  negative. 


448  DISEASES  OF  INFANTS  AND   CHILDREN. 


LATE    HEREDITARY    SYPHILIS.! 

Symptoms  of  tertiary  syphilis  may  be  seen  in  late  child- 
hood. Early  symptoms  may  never  have  existed,  or  have  been 
overlooked  or  forgotten. 


Fig.  158.— Fissures,  or  rhagades  (Dr.  Stowell's  case). 

Hutchinson's  triad,  the  association  of  lesions  of  the  teeth, 
eyes,  and  ears,  is  one  of  the  most  important  diagnostic  feat- 
ures. There  may  also  be  gummata,  especially  of  the  bones. 
Necrosis  and  suppuration  of  the  bones  are  also  frequent. 
Necrosis  of  the  bones  of  the  nose  with  subsequent  depression 
of  the  bridge  of  the  nose  is  a  striking  feature  in  some  case.-. 
The  lymph  nodes  may  be  enlarged. 

Interstitial  keratitis  is  one  of  the  most  frequent  eye  lesions, 
and  the  resulting  corneal  opacities  should  always  be  looked 
for.  This  is  not  necessarily  syphilitic.  The  pigment  of  the 
choroid  may  be  absorbed  in  spots,  especially  toward  the 
periphery.     Chronic  otitis  with  deafness  is  frequent. 

The  teeth  show  marked  changes.  This  applies  only  to  the 
second  or  permanent  teeth.   Hutchinson's  teeth2  consist  of  peg- 

1  Dunlop,  "  Arthritis  from  Congenital  Syphilis,"  Edinburgh  Medical 
Journal,  vol.  xvi.,  1904,  p.  516.- 

2  Hutchinson,  "Mercurial  Teeth,"  Illustration*  of  Clinical  Surgeri/,xo\.  i., 
1878,  p.  53. 


ACUTE  INFECTIOUS  DISEASES.  449 

like  teeth  with  concavities  on  the  grinding  edge,  this  being 
noted  in  the  upper  central  incisors.  Teeth  which  are  peg- 
like or  shaped  like  a  screw-driver  or  which  are  twisted  are 
more  frequently  seen.  A  milk-white  transverse  line  is  some- 
times seen  across  the  upper  central  incisors.  The  teeth  are 
abnormally  soft  and  tliev  are  usually  discolored. 


■Tig.  159.— Sabre  deformity  of  tibia  in  congenital  syphilis 

Subcutaneous  gummata  which  break  down,  leaving  ulcers 
and  later  irregular  scars,  are  also  of  frequent  occurrence. 
Joint  pains  and  swellings  resembling  rheumatism  are  also 
frequently  met  with.  There  may  be  periosteal  nodes,  especi- 
ally of  the  tibia,  which  are  usually  painful  at  night. 

29 


450 


DISEASES  OF  INFANTS  AND   CHILDREN. 


Syphilitic  children  may  show  stigmata  of  degeneration, 
mental  backwardness,  and  nervous  affections. 

Diagnosis. — The  presence  of  bone  lesions,  gummata, 
and  Hutchinson's  triad  are  the  most  important  points. 


Fig.  160.— Hutchinson's  teeth  (after  Fournier) 

Treatment. — Iodic!  of  potassium  should  be  given  in 
large  doses.  It  may  be  alternated  with  the  syrup  of  iodid 
of  iron.     If  improvement  does  not  occur,  mixed  treatment, 


Fig.  161.— Syphilitic  teeth  (after  Fournier). 

consisting  of  inunctions  of  mercurial  ointment  or  the  bi- 
chlorid,  internally,  together  with  iodid  of  potassium,  should 
be  tried. 


ACUTE  INFECTIOUS  DISEASES.  451 

MALARIA,1 

Definition. — This  is  an  infectious  disease  caused  by  the 
hemocytozoa  described  by  Laveran.  It  is  characterized  by 
paroxysms  of  intermittent  fever,  which  may  be  of  a  quo- 
tidian, tertian,  or  quartan  type,  or  by  a  remittent  fever. 
Pernicious  and  chronic  forms  are  also  seen. 

Etiology. — It  is  seen  in  certain  localities,  especially 
where  there  are  marshes  and  undrained  land.  In  temperate 
climates  it  is  most  frequent  in  August,  September,  and  Octo- 
ber, but  some  cases  may  be  seen  in  the  spring.  The  usual 
mode  of  infection  is  through  the  bite  of  a  certain  genus  of 
mosquitoes,  which  act  as  an  intermediate  host  for  the  malarial 
parasite. 

The  Parasite. — This  is  a  hemocytozoa  or  a  parasite  which 


Fig.  1R2.— Various  forms  of  hemocytozoa  (Stevens). 

lives  in  the  red  blood-cells.     It  was  discovered  in  1880  by 
Laveran. 

There  are  three  forms  of  the  parasite  :  the  tertian,  quartan, 
and  sestivo-autumnal. 

The  tertian  parasite  completes  its  cycle  of  development  in 
man  in  forty-eight  hours.  It  is  first  seen  as  a  small  un- 
pigmented  mass  in  the  center  of  a  red  blood-cell.  This  looks 
much  like  the  spore  forms  seen  during  a  chill.  After  a  few 
hours  pigment  may  be  seen.  This  is  fine  and  granular. 
There  is  ameboid  movement  of  the  parasite.  The  pigment 
which  at  first  is  seen  about  the  periphery  becomes  grouped 
in  the  center  of  the  parasite.  The  parasite  breaks  up  into 
about  fifteen  or  twenty  segments.  These  are  the  so-called 
spore  forms  which  enter  the  red  blood-cells  and  repeat  the 
cycle.  Some  of  the  full-grown  parasites  do  not  segment. 
They  are  sexually  differentiated  parasites  and  are  called 
gametoeytes. 

1  Craig,  "  Malaria,"  Boston  Medical  and  Surgical  Journal,  May  27, 1909. 


452  DISEASES  OF  INFANTS  AND   CHILDREN. 

The  quartan  parasite  is  rare  in  the  United  States.  It 
takes  seventy-two  hours  to  complete  its  cycle.  The  granules 
of  pigment  are  larger  and  darker  than  those  of  the  tertian 
organism.  The  red  cell  is  of  a  dark-brass  color.  The  seg- 
ments are  larger  and  only  from  six  to  twelve  are  formed. 
The  chill  occurs  every  fourth  day. 

The  cestivo-autumnal  parasite  is  found  in  the  more  irregu- 
lar fevers.  Its  cycle  probably  takes  from  twenty-four  to 
forty-eight  hours.  It  is  smaller  than  either  of  the  preceding. 
After  a  week  or  two  in  untreated  cases  curious  crescentic 
forms  appear  which  are  larger  than  the  red  cells.  Both  this 
and  the  quartan  form  also  have  gametocytes. 

The  gametocytes  do  not  develop  in  the  blood.  The  male 
parasite  gives  off  flagellar  which  enter  the  female  parasite, 
fecundating  it.  The  malaria  organism  is  taken  into  the 
stomach  of  the  mosquito  with  the  blood.  The  fecundated 
parasite  enters  the  wall  of  the  mosquito's  stomach,  and  two 
days  later  small  refractive  bodies  may  be  demonstrated  in 
the  wall  of  the  stomach.  These  develop  in  about  a  week 
and  break  up  into  myriads  of  spindle-shaped  sporozoids. 
These  get  into  the  salivary  glands  of  the  mosquito  and  thence 
into  the  individual  bitten. 

Malaria-carrying  Mosquitoes.1 — The  species  of  the  genus 
Anopholes  are  the  only  ones  which  act  as  intermediate  hosts. 
The  common  mosquito  is  the  culex.  They  are  easily  distin- 
guished. The  culex  has  small  palpi,  no  spots  on  the  wings 
beyond  the  veins,  and  the  body,  when  resting,  is  parallel  to 
the  wall,  the  two  posterior  legs  usually  crossed  over  the  back. 
The  Anopholes  has  two  large  palpi,  mottled  wings,  and  the 
body  is  inclined  away  from  the  wall. 

Pathology. — Fatal  cases  are  rare  in  young  people  in 
America.  The  changes  are  similar  to  those  found  in  adults. 
There  is  enlargement  of  the  spleen  and  liver,  and  great  de- 
struction of  the  blood-cells.  There  may  be  pigmentation  of 
the  tissues. 

Symptoms. — The  clinical  picture  is  varied.  The  younger 
the  child  the  more  irregular  the  form. 

1  L.  O.  Howard,  Mosquitoes. 


ACUTE  IXFFrTTOrs  DISEASES. 


453 


In  later  childhood  the  attack-  are  similar  to  the  adult 
form.  In  the  tertian  form  the  paroxysm  occurs  every  other 
day.  It'  there  is  a  double  infection,  as  is  frequent  in  chil- 
dren, the  paroxysm  occurs  daily  (quotidian].  In  the  quartan 
form  the  paroxysm  occur-  every  fourth  day.     In  the  aestivo- 


Temp. 

109 

■    :       ) 

106 

.  i 

; 

ior 

106 

105 

;  \  : 

R 

» 

K 

l\ 

104 

» • 

ij\ 

l\ 

103 

/  \ 

rr 

j   \ 

I   i 

102 

!    1    :\ 

j     \ 

\ 

101 

1       ! 

, : 

j 

1 

-         1— 

\ 

f 

100 

\  i     :     :     : 

r 

\ 

i. 

! 

99 

i  ,i.  i 

V— <Ss 

1 

98 

K\J 

97 

96 

:     j     ! 

Temp. 

MM 

!   j    ! 

Resp. 

Stools 

1 

I 

Urine 

_L 

I 

I 

i 

i 

Day  or 
Disease 

; 

Fig.  16o. — Typical  temperature  chart  in  tertian  malaria. 

autumnal  form  there  may  be  an  irregular  intermittent  or 
remittent  fever. 

The  Malarial  Paroxysm. — There  is  a  chill,  sometimes  a 
convulsion  or  only  chilly  sensations  ;  this  may  be  accom- 
panied by  vomiting.  There  is  cyanosis,  and  the  child  feels 
very  ill.  After  from  a  few  minutes  to  an  hour  there  is  high 
fever,  lasting  from  a  half  hour  to  four  or  five  hours.  This 
often  ends  in  a  sweat.  Following  the  paroxysms  the  child 
feels  fairly  well  until  the  next  one. 

Under  five  years  the  paroxysm  may  be  atypical.     There 


454  DISEASES  OF  INFANTS  AND  CHILDREN. 

may  be  only  cyanosis  or  a  peaked  expression  with  fever. 
The  fever  may  be  irregular.  The  disease  may  be  subacute 
or  chronic. 

Malaria  Cachexia. — The  child  is  pale,  sallow,  and  there  are 
marked  anemia,  languor,  loss  of  appetite,  coated  tongue,  and 
often  gastro-intestinal  symptoms.  The  spleen  is  enlarged, 
and  sometimes  the  liver. 

Pernicious  Malaria. — This  is  rare  in  children  in  America. 
There  are  symptoms  of  intense  prostration  and  usually 
marked  nervous  symptoms,  as  convulsions  or  coma.  Unless 
treated  with  subcutaneous  or  intravenous  injections  of  quinin, 
death  usually  results. 

Associated  Conditions  and  Complications. — En- 
largement of  the  spleen,  anemia,  bronchitis,  coryza,  and 
neuralgia  are  the  most  important. 

Diagnosis. — This  is  best  made  by  an  examination  of 
the  blood.  A  fever  which  yields  promptly  to  quinin  is 
probably  malaria.  The  paroxysms,  fever,  enlarged  spleen, 
and  cachexia  are  all  important. 

Prognosis. — With  proper  treatment  the  outlook  is  good 
in  all  except  the  pernicious  forms. 

Prophylaxis.- — The  destruction  of  mosquitoes  and  the 
protection  from  their  bites  are  both  valuable  means  of  pre- 
venting the  disease.  Small  doses  of  quinin  may  also  be  used 
as  a  preventive  in  malarial  districts. 

Treatment. — Quinin  is  a  specific.  A  grain  may  be 
given  for  each  year  of  the  child's  age  until  5  grains  are 
reached.  It  should  be  repeated  every  few  hours  for  a  day 
or  two,  and  then  smaller  doses  given  in  connection  with  iron. 
It  may  be  given  in  the  elixir  glycyrrhiza,  or  the  elixir  of 
yerba  santa,  or  in  the  syrup  of  orange  or  sarsaparilla.  It 
should  be  mixed  with  a  vehicle  just  before  the  dose  is  given. 
In  the  less  severe  cases  the  syrup  of  the  cinchona  alkaloids, 
euquinin,  or  the  tannate  of  quinin  may  be  given. 

For  pernicious  malaria  Bacelli  uses  the  following  : 

B  Quinin  bimuriate 1.0    fgr.  xv) ; 

Sodium  chlorid 0.06  (gr.  j) ; 

Distilled  water 10.0    (Siiss).  -M. 


ACUTE  INFECTIOUS  DISEASES. 


455 


Or  the  following  may  be  used  : 

R   Quinin  bisulphate 1.0    (gr.  xv)  ; 

Tartaric  acid 0.15  (gr.  ij)  ; 

Distilled  water 10.0     (^iiss).— M. 

THE  HOOK-WORM  DISEASE. 

( Uncinariasis;  Ankylostomiasis;    Ground  Itch,  etc.) 
Definition. — A  severe  anemia  caused  by  the  Uncinaria 

Americana  (Necator  Americana,  Stiles). 
The  Parasite. — This  is  7  to  1 1 

nun.  long,  as  thick  as  a  hat-pin,  and 

curved  at  one  end.      The  eggs  are  64 

to  72   mm.  long  and  36   to  40   mm. 

broad.      The  worm  attaches   itself  to 

the  intestinal  wall  first  one  place,  then 

another,  sucks  blood,  and  causes  small 

hemorrhages.      The    eggs    are    passed 

with   the    feces    and   hatch    in    about 

twenty-four  hours.     It  sheds  its  skin 

in    forty-eight    to    seventy-two   hours 

and  again  in  five  to  nine  days,  then 

becomes  an   "  encysted  larva."     This 

gets    into    man    either    through    skin 

wounds  (ground  itch)  or  through  the 

mouth  in  contaminated  food  or  water. 
Symptoms. — The   infection    may 

be  mild,  medium,  or  severe.     The  first 

show  few  symptoms,  but  the  parasite 

and  eggs  can  be  found.     The  medium 

cases  have  a  decided  anemia,  while  the 

severe  cases  have  an  almost  character- 
istic appearance.     There  is  frequently 

an  irritation  of  the  skin  (ground  itch). 

There  is  marked  anemia  and   pallor, 

or    a  yellowish    discoloration    of   the 

skin.     There  may  be   edema,  visible 

pulsation  in  the  neck,  and  the  expres- 
sion   is    anxious    and    stupid.      "Pot 

belly     is  frequent  and  ascites  may  be    c.  w.  stiles.) 


Fig.  164.— Hook-worm  dis- 
ease. CTrild  fourteen  years 
old ;  looks  like  seven  or 
eight.  Has  worked  three 
weeks  in  cotton  mills,  Gads- 


456 


DISEASES  OF  INFANTS  AND   CHILDREN. 


present.  There  is  anorexia  and  a  perverted  appetite  for  all 
sorts  of  inedible  articles.  There  is  salivation,  gastric  pain 
and  tenderness,  and  there  may  be  constipation  or  diarrhea. 
There  may  be  dyspnea,  palpitation  of  the  heart,  and  hemic 
murmurs.  There  maybe  slight  fever.  The  mental  condition 
is  backward  and  there  is  timidity.  There  may  be  somno- 
lence or  insomnia.     The  muscles  are  weak  and  flabby. 


Fig.  165.— Fatal  case  of  hook-worm  disease,  showing  edema.  Patient  died  a 
few  hours  after  the  photograph  was  taken.  Photograph  by  Dr.  H.  H.  Niehuss, 
Wesson,  Ark.    (Courtesy  of  Dr.  C  W.  Stiles.) 

The  Blood. — The  hemoglobin  is  low,  usually  under  50. 
The  red  cells  from  under  1  million  to  2.5  millions.  There 
is  no  leukocytosis,  but  rather  a  leukopenia.  There  is  usually 
eosinophilia  in  the  favorable  cases. 

Diagnosis. — Examine  stools  for  the  eggs,  give  thymol, 
and  look  for  the  parasites.  Blood  in  the  stool  is  sug- 
gestive. 

Prognosis. — Good  in  early  cases,  fair  otherwise,  and 
bad  in  late  cases. 

Treatment. — A  purge  at  night,  in  the  morning  thymol 
3  to  5  grains  up  to  five  years,  5  to  10  grains  from  five  to  ten 
years,  and  10  to  15  grains  in  older  children.  Repeat  in 
middle  of  morning  and  purge  at  noon.  Repeat  this  once  a 
week  until  cured.  Betanaphthol  in  half  the  above  doses  may 
be  used  or  oleoresin  of  male  fern  may  be  given. 


ACUTE  INFECTIOUS  DISEASES.  157 


RHEUMATISM.^ 

Definition. — This  is  an  acute  uoii-contagious  disease, 
the  exact  cause  of  which  is  as  yet  unknown.  In  children 
over  ten  years  of  age  the  disease  resembles  rheumatism  as 
seen  in  adults;  in  younger  children  it  is  liable  to  be  atypical. 

Ktiology. — There  are  numerous  theories  as  to  the  cause. 
These  may  be  mentioned  : 

1.  That  rheumatism  is  an  infectious  disease.  It  often 
occurs  in  epidemics.  Poynton  and  Paine,  Triboulet  and 
Wassermann,  have  all  isolated  a  diplococcus  which  they 
regard  as  the  cause  of  the  disease.  The  infectious  theory  is 
very  generally  accepted. 

2.  That  the  disease  is  due  to  chemic  or  metabolic  causes. 
Lactic  acid  is  frequently  mentioned  as  a  cause. 

3.  That  the  disease  is  of  nervous  origin. 
Rheumatism  is  most  frequently  seen  in  cold,  damp  climates, 

It  affects  certain  families  more  than  others,  and  often  occurs 
in  small  epidemics.  Girls  are  more  frequently  affected  than 
boys.  Exposure  to  cold  and  wet  may  be  the  exciting  cause. 
One  attack  does  not  produce  immunity,  but  rather  predis- 
poses to  a  second. 

Pathology. — There  are  swelling  and  hyperemia  of  the 
synovial  membranes  and  of  the  tissues  about  the  joint.  There 
is  also  a  small  amount  of  effusion  into  the  joint.  Permanent 
joint-changes  are  seen  but  rarely  in  true  rheumatism.  There 
are  no  characteristic  changes  found  at  autopsy. 

Symptoms. — After  ten  years  of  age  the  attacks  resemble 
the  disease  as  seen  in  adults.  There  are  fever,  multiple 
arthritis,  pain,  sweating,  and  frequently  involvement  of  the 
heart.  The  pain  is  not  as  great,  as  a  rule,  as  in  adults,  and 
the  sweat  is  not  so  sour-smelling.  In  younger  children  the 
disease  differs  considerably  from  that  as  seen  in  adults.  The 
joints  are  less  liable  to  be  involved.  There  is  less  fever  and 
hyperpyrexia  is  rare.  Pleurisy,  especially  on  the  right  side, 
may   be    present.     The   younger   the   child   the   greater  the 

"  Barlow,  "  On  the  Diagnosis  and  Treatment  of  Rheumatism  in  Children," 
British  Medical  Journal,  September  15,  1883. 


458  DISEASES  OF  INFANTS  AND  CHILDREN. 

variation.  The  attacks  are  shorter,  lasting  two  weeks  or  less, 
as  a  rule.     Recurrences  are  frequent. 

The  onset  is  usually  sudden,  with  fever  and  pain  in  one  or 
more  joints.  There  may  be  fever  and  puzzling  symptoms 
for  several  days  before  the  joints  are  affected.  There  may  be 
tonsillitis  and  heart  murmurs. 

The  joints,  if  affected,  are  swollen,  hot,  and  painful  ;  but 
the  pain  in  young  children  may  be  trifling.  The  knees, 
ankles,  wrists,  and  small  joints  of  the  hands  and  feet  are  the 
most  frequently  affected  ;  but  any  joint  may  be  involved. 
Under  seven,  acute  articular  rheumatism  is  not  common,  and 
under  three  it  is  rare,  but  may  be  seen.  In  young  children 
the  diagnosis  is  made  on  the  association  of  manifestations, 
sometimes  one  and  sometimes  another  symptom  being  most 
marked. 

Heart  Lesions. — The  heart  is  involved  in  children  more 
than  it  is  in  adults.  There  may  be  either  pericarditis  or 
endocarditis,  both  of  which  are  frequently  overlooked.  The 
heart  should  be  carefully  examined  at  each  visit  when  rheu- 
matism is  suspected.  Chronic  heart  lesions  affecting  the 
valves  are  nearly  all  of  rheumatic  origin. 

Chorea. — This  is  a  frequent  accompaniment  or  sequela  of 
rheumatism.  In  about  one-half  of  the  cases  of  chorea  there 
is  a  history  of  rheumatism. 

Tonsillitis. — This  is  frequently  associated  and  may  be  the 
first  manifestation  of  the  attack. 

Skin  Lesions. — Various  rashes  are  seen.  Miliary  and  ery- 
thematous rashes  are  most  frequent.    Purpura  may  be  present. 

Subcutaneous  Nodules. — These  are  as  frequently  seen  in 
America  as  in  England.  They  are  small,  transitory  nodules, 
varying  in  size  from  a  split  pea  to  a  pin-head.  They  are 
most  frequent  along  the  tendons  and  bones,  which  are  cov- 
ered only  by  skin. 

Nervous  Symptoms. — Nervousness,  nightmare,  headaches, 
and  even  severer  symptoms  may  be  met  with. 

Anemia. — There  is  always  more  or  less  anemia  of  a  sec- 
endary  form. 

Muscular  Rheumatism. — The  pain  may  be  in  the  muscles, 


ACUTE  INFECTIOUS  DISEASES.  459 

and  the  muscles  may  often  be  tender  to  touch  in  spasmodic 
contraction,  as  in  rheumatic  torticollis. 

Duration. — Rheumatism  in  children  usually  lasts  two 
weeks  or  less,  the  attack  being  shorter  and  somewhat  less 
severe  than  in  adults.  The  tendency  to  relapses  and  recur- 
rences is  greater. 

Diagnosis. — This  is  often  extremely  difficult  in  young 
children.  Remember  that  true  rheumatism  rarely  leaves  the 
joint  with  any  permanent  change.  The  following  are  most 
frequently  mistaken  for  rheumatism. 

Scurvy. — The  nature  of  the  food,  the  bleeding  from  the 
gums,  the  ecchymoses,  the  subperiosteal  hemorrhages,  and 
absence  of  fever  should  all  be  considered. 

Rickets. — Early  rickets  can  be  told  by  the  sweating  about 
the  head,  the  restlessness,  the  rickety  rosary,  and  craniotabes. 

Multiple  Secondary  Arthritis. — This  may  be  seen  after 
almost  any  acute  infection.  It  is  most  frequently  seen  after 
gonorrhea,  scarlet  fever,  cerebrospinal  meningitis,  and  dysen- 
tery. 

Septic  Arthritis. — There  is  high  temperature  with  marked 
local  and  constitutional  disturbances.  The  joint  is  filled 
with  a  purulent  effusion.     If  in  doubt,  aspirate  the  joint. 

Acute  Osteomyelitis. — There  is  marked  local  and  constitu- 
tional disturbance.  The  swelling  is  below,  rather  than  in  the 
joint. 

Prognosis. — Usually  good.  Involvement  of  the  heart 
is  the  most  serious  feature. 

Treatment. — Put  the  child  to  bed ;  keep  him  there. 
Protect  from  cold  and  draughts.  Use  flannel  underwear 
and  nightgowns.  Locally  Fuller's  lotion  (carbonate  of  soda, 
3vj  ;  laudanum,  1  oz.  ;  glycerin,  2  oz.  ;  water,  9  oz.),  applied 
hot  on  flannel  cloths,  gives  relief.  Chloroform  liniment  may 
also  be  used.  If  very  painful,  fix  the  joint  at  rest  in  a  well- 
padded  splint.  "  Fire  "  the  joint  with  the  Paquelin  cautery  ; 
this  should  produce  just  a  slight  degree  of  glossiness  of  the 
skin. 

Internally  the  salicyl  compounds  or  alkalis  may  be  used. 
One  grain  of  salicin  may  be  given  for  each  year  of  the  child's 


460  DISEASES  OF  INFANTS  AND   CHILDREN* 

age,  and  repeated  every  hour  or  two  until  the  pain  is  relieved, 
and  then  less  frequently.  Salicylic  acid,  salicylate  of  soda, 
aspirin,  or  oil  of  winter-green  may  be  used.  Morphia  or 
opiates  may  be  necessary  if  the  salicylates  do  not  relieve  the 
pain.  Bicarbonate  of  potassium  may  be  given  to  render  the 
acid  urine  neutral.    Iron  and  tonics  should  be  used  afterward. 

Chronic  Fibrous  Rheumatism. — Repeated  attacks 
of  rheumatism  may  occasionally  lead  to  thickening  of  the 
tissues  about  the  joints  and  of  the  joint  capsule  itself.  There 
may  be  endocarditis,  pericarditis,  or  rheumatism  nodules. 

Diagnosis. — This  is  made  on  the  repeated  attacks  of  rheu- 
matism and  the  involvement  of  the  heart.  As  a  rule,  attacks 
of  joint  pain  attended  with  permanent  changes  in  the  joint 
are  not  rheumatism. 

Prognosis. — This  is  good  as  regards  life,  but  bad  as  regards 
the  joints.  The  disease  is  apparently  uninfluenced  by  treat- 
ment. 

Treatment. — Salicyl  derivatives,  iodin,  and  tonics  should 
be  given.  Passive  movements,  massage,  and  the  use  of  hot 
air  at  high  temperature  may  all  be  tried.  A  dry3  equable 
climate  is  desirable. 


DISEASES  OF  THE  JOINTS.  461 

DISEASES    OF   THE   JOINTS. 

ARTHRITIS  DEFORMANS.1 

Definition. — A  chronic  joint  disease  characterized  by 
repeated  exacerbations,  each  of  which  leaves  the  joints  a  little 
more  disabled. 

Ktiology. — This  is  obscure.  In  some  cases  there  is  the 
family  history  of  joint  troubles.  Some  cases  are  evidently 
due  to  faulty  metabolism,  and  still  others  to  absorption  of 
toxins  from  some  focus  of  infection. 

Pathology. — There  are  two  classes  of  cases.  In  one 
there  is  a  hypertrophy  of  the  bone,  with  exostoses  and  the 
formation  of  new  bone  tissue,  which  may  "  solder,"  as  it 
were,  the  joints  together.  In  the  second  class  there  is 
atrophy  of  the  tissues  about  the  joint,  and  ankylosis  finally 
results  from  erosions.      There  is  marked  deformity. 

Symptoms. — In  some  cases  there  is  a  gradual  onset, 
with  progressive  joint  changes,  and  later  atrophy  of  the  mus- 
cles and  deformity.  In  others  there  are  repeated  attacks  of 
swelling  of  the  joint,  some  pain,  little  or  no  temperature,  and 
a  rapid  pulse  rate.  The  lymph  glands  are  usually  enlarged. 
There  is  a  form  known  as  Still's  disease,2  in  which  the  spleen 
is  very  much  enlarged  and  early  permanent  disability  from 
joint-changes. 

Diagnosis. — From  rheumatism  by  the  marked  swelling 
and  little  pain,  the  persistence  of  the  swelling  for  some  time, 
the  absence  of  any  tendency  to  move  from  joint  to  joint,  a 
high  pulse  rate,  and  little  or  no  temperature. 

Prognosis. — As  regards  life  good,  but  the  patient  is 
liable  to  be  eventually  badly  crippled  and  have  poor  health. 

Treatment. — Good  food,  out-of-door  life,  massage,  pas- 
sive   movements,   etc.      Firing   the   joint  during  the  acute 

1  Nathan,  "  The  Nature,  Diagnosis,  and  Treatment  of  Metabolic  Osteo- 
arthritis, So-called  Rheumatoid  Arthritis,  Arthritis  Deformans,  Etc." 
American  Journal  of  Medical  Sciences,  vol.  exxxvii.,  1909,  p.  817. 

-  Still,  "Medical  and  Surgical  Transactions,''  London,  1897,  vol.  lxxx., 
p.  47. 


462 


DISEASES  OF  INFANTS  AND   CHILDREN. 


attacks,  rest  in  bed,  warmth.      Furuucalosis  or  any  source 
of  chronic  absorption  of  toxin  should  be  treated. 

Spondylitis    Deformans. — Arthritis   deformans  may 
attack  the  spinal  column  and  proximal  joints,  causing  stiff 


Fig.  166.— Arthritis  deformans. 


back,    pain,   and  nervous  symptoms.     The   treatment  is  to 
immobilize  the  back  by  a  cast  or  suitable  brace.1 

ACUTE  ARTHRITIS  OF  INFANTS.2 
(Acute  Epiphysitis;   Acute  Suppurative  Synovitis.) 

Definition. — An  acute  pyogenic  infection  of  the  joint 
with  abundant  pus-formation. 

Etiology. — It  is  a  disease  of  early  life ;  most  cases  occur 
during  the  first  year.     The  infection  may  spread  from  an 

1  Ruhrah,  American  Journal  of  the  Medical  Sciences,  November,  1903. 

2  Townsend,  American  Journal  of  the  Medical  Sciences,  January,  1901. 


DISEASES   OF  WE  JOINTS.  463 

osteomyelitis  or  it  may  start  in  the  joint.  It  may  follow  an 
acute  infectious  disease  or  other  foci  of  suppuration. 

Symptoms. — The  onset  is  sudden,  usually  with  marked 
constitutional  symptoms.  The  joint  is  swollen  and  tender. 
Later  the  character  of  the  trouble  is  very  apparent.  The 
hips,  knee,  shoulder,  and  wrist  are  the  most  frequently 
affected. 

Diagnosis. — See  Eheumatism.  Aspiration  should  be 
used  in  cases  of  doubt. 

Prognosis. — Good  if  opened  and  drained  early  ;  other- 
wise ankylosis  or  a  flail  joint  may  follow.  Death  may  result 
fr<  >m  septicemia. 

Treatment. — Surgical. 

TUBERCULOUS  ARTHRITIS  AND  OSTITIS. 

Chronic  tuberculosis  of  the  joints  is  really  a  surgical  dis- 
order, but  the  early  diagnosis  and  treatment  is  so  important 
that  it  is  included. 

Etiology. — The  onset  rarely  occurs  before  two  years 
of  age,  and  is  infrequent  after  eight.  It  most  often  fol- 
lows an  acute  infectious  disease,  as  measles  or  whooping- 
cough,  but  may  come  on  in  children  in  apparent  health. 
It  is  usuallv  primary,  but  tuberculosis  of  other  parts  of 
the  body  may  follow.  Sometimes  the  disease  develops  after 
an  injury. 

Pathology. — The  spine,  knee,  and  hip  are  most  frequently 
affected  in  the  order  named,  and  the  ankle,  elbow,  wrist,  and 
shoulder  follow,  but  much  less  often.  The  disease  usually 
begins  in  the  bone  near  the  joint,  and  involves  the  joint 
later.  There  is  a  tuberculous  ostitis,  which  may  become 
quiescent  or  which  may  go  on  to  suppuration.  The  joint 
becomes  involved  by  extension.  All  the  structures  about  the 
joint  may  be  involved,  and  the  pus  may  burrow  along  the 
muscle  sheaths  and  sinuses  result. 

Caries  of  the  Spine  (Pott's  Disease). — This  is  a 
tuberculous  inflammation  of  the  vertebrae  which  extends  to  the 
surrounding  structures  and  involves  the  joints  and  sometimes 


464 


DISEASES  OF  INFANTS  AND   CHILDREN? 


the  meninges,  nerve  roots,  and  cord.  Under  the  weight  of 
the  body  the  spine  becomes  deformed,  which  progresses  as 
the  softening  goes  on.  The  resulting  kyphosis  is  commonly 
called  "  hunch  back."  Nearly  three-fourths  of  the  cases  are 
dorsal ;    of   the  remainder,  the   lumbar   slightly  exceed   the 

cervical. 

Symptoms. — Early  symptoms  are 

obscure,  and  diagnosis  may  not  be 

made     until     there    is     deformity. 

Early  symptoms  are  very  important. 

(a)  Rigidity  of  spine.  In  stoop- 
ing, etc.,  the  back  is  kept  rigid. 

(b)  Referred  pain.  This  may  be 
any  place  supplied  by  the  spinal 
nerves  of  the  part  affected.  Ab- 
dominal pain  is  frequent  where  the 
dorsal  region  is  affected.  Pain  may 
come  on  at  night. 

(c)  The  child  assumes  a  position 
■V  such  as  will  relieve  pressure  on  the 
i  a  It                          vertebrae. 

(d)  There  may  be  pressure  paral- 

Cervical  Form. — Pain  is  usually 
of  a  neuralgic  type,  either  occipital 
or   on  side  of  neck.     This  should 
always   lead  to  a  careful   examina- 
tion of  the  spine.    There  may  be  pain  only  on  motion  ;  there 
may  be  stiff  neck.     Paralysis  or  retropharyngeal  abscess  may 
be  the  first  thing  noted. 

Dorsal  Form. — There  may  be  intercostal  neuralgia  or  ab- 
dominal pain.  Child  sleeps  lying  with  abdomen  downward 
(prone  position).  The  spine  is  stiff  and  held  so.  Early 
there  may  be  frontal  lordosis,  the  backward  kyphosis  coming 
later. 

Lumbar  Form. — The  pelvis  is  tilted  to  one  side,  causing 
lateral  curvature  of  spine.  The  pain  is  usually  referred  to 
hip  or  knee,  and  there  is  usually  limping  on  one  side,  often 


Fig.  167. — Tuberculosis  of  dorsal 
and  lumbar  vertebrae. 


DISEASES  OF  THE  JOINTS.  465 

mistaken  for  hip  or  knee  disease.     Deformity  is  usually  late 
in  appearing. 

Diagnosis. — The  child  should  be  naked  and  the  position 
noted,  also  the  presence  of  any  deformity  of  spine  or  else- 
where, and  the  mobility  of  the  spine  tested.  Paralysis  and 
abscess  should  be  looked  for.  "The  child  walks  with  its 
legs,  but  not  its  back."  The  knee  and  hip  are  bent  in  pick- 
ing up  objects  from  the  floor,  while  the  spine  is  held  stiff. 
The  disease  is  made  more  apparent  if  a  normal  child  is  ex- 
amined at  the  same  time.  Lumbar  cases  should  be  differ- 
entiated from  hip  cases. 

The  spine  may  be  bent  in  rickets  and  in  malnutrition,  but 
this  is  most  frequent  under  two  years  of  age  ;  there  are  other 
signs  of  rickets  or  malnutrition,  and  the  back  is  mobile  anc* 
not  rigid.  The  deformity  is  usually  dorsal,  and  disappears 
more  or  less  if  an  attempt  is  made  to  straighten  the  spine. 

Rotary  lateral  curvature  is  usually  seen  in  girls  from 
eleven  to  fourteen,  and  there  is  neither  rigidity  nor  pain. 

Prognosis. — The  disease  is  very  chronic,  and  it  #is  usually 
from  one  to  three  years  before  repair  starts.  Relapses  and 
exacerbations  are  common,  and  are  due  to  traumatism,  lack 
of  proper  support,  and  improper  treatment.  Abscesses  occur 
in  about  20  per  cent,  of  the  cases,  and  paralysis  in  about  50 
per  cent.,  when  the  disease  is  in  the  lower  cervical  or  upper 
dorsal  region.  Death  takes  place  in  about  10  per  cent,  of 
the  cases.  The  amount  of  deformity  varies  with  the  site  of 
the  disease,  the  treatment,  and  especially  on  how  early  it  is 
begun.     If  begun  very  early  there  may  be  little  or  none. 

Treatment. — The  general  treatment  is  important,  and  is  the 
same  as  in  any  other  form  of  tuberculosis,  and  is  in  these 
cases  too  frequently  neglected.  The  local  treatment  is  best 
carried  out  by  an  orthopedic  specialist,  and  consists  in  keep- 
ing the  spine  at  rest  and  taking  the  weight  off  of  it  by  means 
of  plaster  jackets  or  specially  constructed  apparatus. 

Tuberculous  Articular  Ostitis  of  the  Hip  (Hip- 
joint  Disease) ;  Morbus  Coxarius. — This  begins  in  the 
head  of  the  femur  or  acetabulum  as  an  inflammation  of  the 
bone — first  stage ;  spreads  to  the  joint — second  stage ;  and 

30 


466  DISEASES  OF  INFANTS  AND   CHILDREN. 

may  soften  and  destroy  the  joint  with  considerable  resulting 
deformity — third  stage. 

First  Stage. — There  is  early  morning  stiffness  and  slight 
lameness,  slight  tenderness  about  the  hip,  disinclination  to 
walk,  then  pain,  usually  referred  to  knee.  A  little  later 
there  are  u  shooting  pains  "  at  night,  which  cause  the  child  to 
cry  out  suddenly.  Later  there  is  lameness.  This  stage  may 
last  weeks,  months,  or  years. 


Fig.  168.— Position  in  early  tuberculosis       Fig.  169.— First  stage  in  tuberculosis  of 
of  the  bip-joint.  the  hip.     Note  position  and  apparent 

lengthening. 

The  physical  signs  are  flattening  of  the  gluteal  fold,  which 
may  be  single,  and  of  the  buttock,  atrophy  of  the  leg  on  the 
affected  side ;  the  trochanter  is  prominent.  The  weight  is 
carried  on  the  sound  leg.  The  affected  side  should  be  com- 
pared to   the  well  one  standing  and  lying  down,  both  legs 


DISEASES  OF  THE  JOINTS. 


467 


should  be  rotated,  flexed,  extended,  abducted,  and  adducted. 
A  comparison  with  the  well  leg  reveals  limitation  of  motion 
which  could  often  not  otherwise  be  detected.  Later  on  the 
hip  may  be  fixed. 

Second  Stage. — This  gradually  follows  the  above,  occasion- 
ally it  comes  on  suddenly.  The  leg  is  apparently  lengthened, 
the  foot  turned  out,  the  thigh  flexed  and  rotated  outward. 
There  is  muscular  spasm  which  limits  or  prevents  movement 
of  the  hip  ;  there  may  be  infiltration  of  the  joint  and  abscesses 
and  sinus  formation.  This  stage  lasts  weeks,  months,  or 
years,  and  the  disease  may  not  progress  further. 

Third  Stage. — There  is  marked,  real  deformity,  due  to  de- 


Fig.  170. — Late  tuberculosis  of  hip-joint. 

struction  of  the  joint  and  drawing  up  of  the  leg  by  muscular 
action.  The  leg  is  shortened  from  one  to  four  inches.  The 
foot  is  turned  inward,  the  thigh  flexed,  adducted,  and  rotated 
inward.  The  trochanter  is  above  Nelaton's  line  and  the 
trochanter  against  the  ilium.  There  is  marked  curvature  of 
the  spine  and  atrophy  of  the  leg.  There  may  be  abscesses 
and  sinuses. 

Diagnosis. — Shooting  pains,  any  lameness,  pains  in  knee  or 
leg  should  lead  to  examination.  In  the  first  stage  mistakes 
are  easily  made,  and  sprains,  poliomyelitis,  rheumatism, 
tuberculosis  of  the  lumbar  vertebrae,  and  inflammations  of  the 


468  DISEASES  OF  INFANTS  AND   CHILDREN. 

soft  parts  must  all  be  excluded.  Appendicitis  or  peri- 
nephritic  abscess  may  cause  a  drawing  up  of  the  hip  and  be 
mistaken  for  the  second  stage. 

Prognosis. — About  25  per  cent.  die.  If  the  disease  is 
treated  in  the  first  stage  there  may  eventually  be  little  or  no 
deformity ;  if  treatment  is  started  in  the  second  stage  there  is 
always  some  deformity,  and  if  in  the  third,  there  is  always 
marked  deformity. 

Treatment. — This  consists  in  rest,  immobilization,  and  re- 
lieving the  joint  from  carrying  the  weight  of  the  body  by 
means  of  proper  apparatus.  The  patient  can  usually  be  up 
and  about  except  in  the  third  stage. 

Tuberculous  Articular  Ostitis  of  the  Knee 
(White  Swelling). — The  changes  are  similar  to  the  above. 
The  disease  usually  begins  in  the  inner  condyle  of  the  femur 
and  extends  to  the  joint.  The  amount  of  change  is  variable. 
There  may  be  only  a  slight  synovitis  or,  on  the  other  hand, 
there  may  be  complete  destruction  of  the  joint.  Abscesses 
and  sinuses  may  be  present. 

Symptoms. — There  are  slight  lameness,  tenderness,  the 
knee  is  flexed,  and  there  is  some  stiffness  and  pain.  Later 
there  is  swelling,  atrophy  of  the  muscles  above  and  below 
the  joint,  and  a  deformity,  consisting  in  flexion  and  outward 
rotation.  The  disease  lasts  months  or  years,  wTith  remissions 
and  relapses. 

Prognosis. — This  is  better  than  the  other  forms  as  regards 
life,  and  if  treatment  is  instituted  early  there  may  be  little 
deformity.     This  is  variable,  however. 

Diagnosis. — In  infants  scurvy  must  be  excluded,  also  syno- 
vitis, and  in  older  children  acute  rheumatism. 

Treatment. — Rest  and  immobilization  by  means  of  proper 
apparatus. 

OTHER  FORMS  OF  ARTHRITIS, 

Quite  a  number  of  other  forms  of  arthritis  are  met  with  in 
infants  and  young  children,  the  chief  of  which  is,  perhaps, 
the  gonorrheal  arthritis  which  occurs  in  very  early  life, 
usually  following  a  gonorrheal  ophthalmia. 

Gonorrheal  Arthritis. — This   may  be  seen  in  the  course  of 


DISEASES   OF  THE  JOINTS. 


469 


ward    epidemics   of  gonorrhea.     There  may  or  not   be  con- 
junctivitis or  genital  lesions. 

The  clinical  picture  varies  a  great  deal,  and  in  some  cases 
the  condition  is  very  acute,  the  joint  looking  as  if  suppuration 
would  take  place.  As  a  rule,  in  three  or  four  weeks  recovery 
takes  place  without  surgical  interference.  Sometime-  the  joints 
suppurate,  owing  to  a  secondary  infection  with  pus  germs. 
There  may  he  only  one  joint  or  there  may  be  a  number  of 
joints  affected. 


Fig.  171.— Syphilitic  arthritis. 


Meningococcal  Arthritis. — Arthritis  may  be  met  with  in 
epidemic  cerebrospinal  fever  and  postbasic  meningitis.  One 
or  more  joints  may  be  affected,  the  special  feature  being  that 
the  swelling  is  peri-articular  rather  than  intra-artieular.  The 
swelling  is  not  especially  painful. 

Acute  Tuberculous  Arthritis. — This  is  very  rare,  but  is 
occasionally  met  with,  and  should  be  borne  in  mind  in 
making  a  diagnosis. 


470  DISEASES  OF  INFANTS  AND  CHILDREN. 

Pneumococcal  Arthritis. — This  is  exceptional.  It  occurs 
in  the  course  of  pneumonia  or  a  pneumococcal  empyema. 

Acute  Kheumatism. — Swelling  of  the  joints  in  rheumatism 
in  children  under  five  years  of  age  is  exceedingly  rare,  but 
arthritis  due  to  rheumatism  may  occasionally  occur  in  young 
children. 

Arthritis  is  Associated  with  Hemophilia. — Several  forms  of 
joint  affection  may  be  met  with  in  this  condition.  There 
may  be  an  acute  infective  arthritis ;  there  may  be  hemor- 
rhages into  the  joints,  and  there  may  be  an  arthritis  de- 
formans. 

Congenital  Syphilis. — This  rarely  affects  the  joints  under 
five  years  of  age,  and  yet  occasionally  one  meets  with  marked 
cases.  In  early  life  syphilitic  epiphysitis  is  not  uncommon, 
and  may  be  mistaken  for  a  multiple  arthritis.  It  comes  on 
usually  in  the  first  three  months,  there  is  swelling  about  the 
epiphyses,  pain,  loss  of  motion.  It  may  be  mistaken  for  a 
birth  palsy. 


DISEASES  OF  THE  BONES.  471 

DISEASES  OF  THE  BONES* 

ACUTE  OSTEOMYELITIS. 

This  may  be  overlooked  on  account  of  several  features  of 
the  disease.  It  may  be  mistaken  for  rheumatism,  especially 
when  it  is  accompanied  with  pericarditis  and  swelling  about 
the  joint.  It  may  be  mistaken  for  erysipelas.  The  diagnosis 
can  usually  be  made  by  deep  pressure,  which  in  erysipelas 
produces  no  especial  amount  of  pain,  but  does  in  osteomye- 
litis. It  should  be  remembered  that  delirium  is  one  of  the 
characteristic  features  of  the  disease,  and  the  bone  may  be 
overlooked  on  account  of  this.  On  examination  there  may 
be  found  to  be  a  thickening  of  the  shaft  of  the  bone  and  ten- 
derness on  pressure.  The  joint  immediately  below  may  ap- 
parently be  swollen,  but  it  is  easy  to  determine  by  pressure 
that  the  pain  is  in  the  shaft  of  the  bone  and  not  in  the  ioint. 
The  treatment  is  surgical. 

MULTIPLE  EXOSTOSES. 

These  are  hereditary  and  are  due  to  abnormal  development 
of  the  bones.  The  exostoses  vary  in  size,  and  are  most  fre- 
quent on  the  long  bones  about  the  epiphyses.  They  come  on 
most  frequently  about  puberty,  when  the  bone  development 
is  most  rapid.  When  the  growth  of  bone  ceases,  they  stop 
growing.  Unless  giving  trouble,  they  should  be  let  alone. 
If  they  cause  symptoms  from  pressure  on  the  nerves  or  ves- 
sels they  should  be  removed. 

OSTEOGENESIS  IMPERFECTA.1 

This  is  a  rare  congenital  disease  of  the  bones,  changes 
taking  place  during  fetal  life  and  also  later.  At  birth  the 
skin  is  thickened,  and  the  infants  present  an  obese  appear- 
ance. If  the  child  grows  there  are  bending  deformities  of 
the  extremities.  The  bones  are  exceedingly  brittle,  and  the 
most  characteristic  feature  is  frequent   fractures,  which  usu- 

1  Xathan,  American  Journal  of  Medical  Sciences,  January,  1905,  p.  1. 


472  DISEASES  OF  INFANTS  AND   CHILDREN. 

ally  heal  promptly.  The  cranium  is  usually  enlarged  and 
deformed.  Little  is  known  about  the  cause  or  pathology  of 
the  disease.  Most  of  the  cases  die  early,  though  some  sur- 
vive until  later  in  life. 

The  patient  should  be  handled  carefully  to  avoid  fracture, 
and  in  mild  cases  braces  may  be  used  to  protect  the  limbs. 
No  effective  treatment  has  yet  been  instituted. 


DISEASES  NOT*  OTHERWISE  CLASSIFIED.  473 


DISEASES  NOT  OTHERWISE  CLASSIFIED, 

PELLAGRA. 

Definition. — A    constitutional   disease   frequently  over- 
looked   in    childhood.      The  pathology  and  symptomatology 


Fig.  172.— Lesions  on  hands  and  face.  Photograph  from  Dr.  Eugenio  Bravatta, 
Mombello,  Italy.  'Courtesy  of  Dr.  William  Weston.  Columbia,  S.  C,  from  The 
American  Journal  of  Diseases  of  Children,  February,  1914.  j 


474  DISEASES  OF  INFANTS  AND  CHILDREN. 

are  extremely  varied.  The  chief  manifestations  are  upon 
the  skin  in  the  alimentary  canal  and  the  nervous  system. 

Etiology. — Seen  at  all  ages,  and  sexes  are  equally  affected. 
Most  of  the  attacks  occur  in  spring  or  early  summer  or  au- 
tumn, rarely  in  cold  weather.  Sunlight  aggravates  the  rash. 
It  is  usually  seen  in  unsanitary  surroundings.  The  cause  of 
the  disease  is  not  known  at  the  present.  One  theory  is  that 
it  is  due  to  spoiled  maize.  Sambon  believes  it  to  be  a  para- 
sitic disease  transmitted  by  a  species  of  simulium. 

Pathology. — There  is  usually  anemia  and  cachexia  and 
emaciation.  There  are  changes  in  the  meninges,  brain,  and 
spinal  cord.    The  erythema  is  trophoneurotic  in  origin.    There 


Fig.  173.— Hands  from  white  girl,  aged  six.  Fifth  attack  of  pellagra.  First 
attack  occurred  before  the  age  of  two.  (Courtesy  of  Dr.  William  Weston,  Columbia, 
S.  O,  from  The  American  Journal  of  Diseases  of  Children,  February,  1914.) 

are  atrophic,  sometimes  ulcerative,  changes  in  the  intestinal 
tract. 

Symptomatology. — The  disease  generally  comes  on 
gradually,  either  with  changes  in  the  skin  or  digestive  symp- 
toms. There  is  usually  diarrhea,  sometimes  constipation.  The 
digestive  disturbances  are  more  common  after  the  fourth  year. 
The  nervous  symptoms  consist  of  marked  insomnia,  paresthe- 
sia, exaggerated  knee-jerk,  and  there  is  often  mental  depres- 
sion. The  rash  is  symmetrical,  chiefly  on  the  hands  and 
face,  sometimes  on  other  parts  of  the  body,  sometimes  wet 
and  sometimes  dry.  It  is  intensified  by  light.  In  the  dry 
form  there  is  an  erythema  with  a  tendency  to  fissures  and 
repeated  attacks  of  thickening  of  the  skin. 


DISEASES  NOT  OTHERWISE  CLASSIFIED. 


475 


Diagnosis. — On  the  symptom-complex,  consisting  of  a 
red  tongue,  fissured  lips,  diarrhea,  headache,  insomnia,  rest- 
lessness, paresthesia.  In  the  later  cases  rigidity  of  the  mus- 
cles and  even  spasms,  and  photophobia.  There  is  muscular 
weakness  of  the  legs.  The  presence  of  the  skin  lesion  makes 
the  diagnosis  almost  certain. 


Fig.  174.—  Wet  variety  of  pellagra  in  an  eighteen-rnonth-old  child.  Patient  of 
Dr.  J.  J.  Watson.  (Courtesy  of  Dr.  William  Weston.  Columbia,  S.  C,  from  The 
American  Journal  of  Diseases  of  Children,  February.  1914. 

Prognosis. — The  younger  the  child  the  less  favorable 
the  prognosis.  Infants  nursing  the  breasts  of  pellagrous 
-mothers  become  marantic  unless  the  diet  is  changed.  From 
four  to  ten  years  of  age  the  attack  is  more  mild. 

Treatment. — If  the  mother  has  pellagra  the  child  should 
be  weaned.  Improved  hygiene  and  change  of  climate  if 
possible.  The  child  should  be  kept  out  of  the  sunshine.  Iron 
or  arsenic  may  be  given  internally. 


476  DISEASES  OF  INFANTS  AND   CHILDREN. 


THERAPEUTICS  FOR  INFANTS  AND  CHILDREN. 

Prescribing  for  children  and  ordering  therapeutic  meas- 
ures other  than  drugs  deserve  especial  attention.  There  are 
certain  well-known  principles  and  rules  that  should  be  borne 
constantly  in  mind.  These  may  be  briefly  expressed  as  fol- 
lows : 

Never  give  a  dose  of  medicine  without  a  definite  indica- 
tion. 

Never  give  an  unnecessary  dose  of  medicine. 

If  a  placebo  is  prescribed,  give  a  harmless,  palatable 
dose. 

Give  small  doses,  often  repeated,  as  a  rule,  in  preference 
to  larger  doses  at  long  intervals,  unless  there  is  some  especial 
reason  for  the  latter  proceeding. 

Never  give  an  unpalatable  dose  where  a  pleasant-tasting 
one  can  be  given  instead. 

Avoid  drugs  that  produce  nausea  and  so  destroy  the  appe- 
tite and  endanger  nutrition,  except  in  the  few  indications  for 
so  doing. 

Give  simple  prescriptions.  In  most  instances  one  drug 
by  itself  will  give  better  results  than  a  number  mixed 
together.     There  are,  however,  many  exceptions  to  this. 

As  a  rule  children  like  syrups  without  too  much  flavoring. 
Avoid  as  far  as  possible  the  highly  seasoned  and  flavored 
elixirs.     Properly  diluted,  these  may  be  very  acceptable. 

Bitter  medicines  are  frequently  well  taken,  especially  by 
young  infants,  if  they  are  well  diluted  with  water.  In  many 
instances  the  mixtures  intended  to  disguise  bitter  drugs  are 
worse  than  the  drugs  themselves. 

As  far  as  possible  always  see  and  taste  every  medicine, 
unless  certain  as  to  what  the  result  of  the  combination  will  be. 

Size  of  the  Dose  of  Medicine. — This  is  an  important 
and  often  a  perplexing  problem.  There  have  been  many  rules 
devised,  and  probably  none  better  than  the  old  one  of  add 
twelve  to  the  age  in  years  and  divide  the  age  by  the  sum. 


THERAPEUTICS  FOB  INFANTS  AND   CHILDREN.  477 

This  gives  the  proportion  of  the  adult  dose  which  should  be 
proscribed.     Example  :  For  a  child  of  three  years, 

3  1 


12  +  3  5 

This  does  not  apply  to  all  drugs,  for  some  are  especially  well 
tolerated,  while  others  are  badly  borne,  even  in  the  indicated 
proportions.  Cowling's  method  is  to  divide  the  following 
birthday  of  the  child  by  24.  For  example,  at  two  years, 
3  divided  by  24  equals  i.  Clark  has  suggested  that  the 
dose  should  correspond  to  the  weight,  assuming  150  pounds 
is  the  average  weight,  to  which  the  dose  is  1.  If  the  weight 
be  divided  by  150  the  resulting  fraction  represents  the 
proper  proportion  of  the  dose  for  that  particular  case.  For 
example,  the  proper  dose  for  a  baby  of  10  pounds  would 
be  -1- 

15. 

For  infants  under  one  year  great  care  should  be  exercised. 
Fiud  the  dose  for  an  infant  of  one  year  and  give  about  one- 
twelfth  of  the  dose  for  each  month  of  the  child's  age.  Opium 
should  always  be  used  with  the  greatest  caution  in  the 
young. 

The  doses  in  the  table  on  pages  478-480  are  what  may  be  re- 
garded as  safe  initial  doses.  It  should  be  remembered  that  no 
hard-and-fast  rules  can  be  made  for  estimating  the  size  of  the 
dose  for  children,  and  that  in  some  instances  the  doses  given  may 
be  rather  larger  than  would  be  warranted,  as  in  a  very  small, 
weak  child,  for  example,  and  in  many  more  instances  the 
size  of  the  dose  may  be  increased  with  great  benefit.  Almost 
without  exception  the  doses  given  have  been  used  by  the 
author  in  actual  practice. 


478 


DISEASES  OF  INFANTS  AND   CHILDREN. 


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THERAPEUTICS  FOR   INFANTS  AND  CHILDREN.   481 

Antipyretics. — These  are  used  to  reduce  temperature. 
Study  the  natural  history  of  disease,  and  unless  the  tem- 
perature is  higher  than  it  should  ordinarily  be  in  the  disease 
which  causes  it,  let  it  alone,  unless  attended  by  nervousness, 
restlessness,  or  other  troublesome  symptoms.  A  temperature 
of  more  than  104J°  F.,  from  whatever  cause,  should  be 
reduced  if  possible. 

The  best  antipyretic  is  the  external  application  of  cold. 
This  may  be  done  in  the  following  ways  : 

Ice  Bags. — These  may  be  applied  to  the  head,  to  the 
carotids,  over  the  heart,  and  over  the  wrists.  If  there  is 
local  inflammation  they  may  be  placed  over  the  seat  of  the 
disease.  They  are  an  efficient  way  of  relieving  the  pain, 
especially  in  that  caused  by  the  congestion  or  inflammation 
of  a  serous  membrane,  as  in  pericarditis  or  pleurisy. 

Cold  Pack. — This  is  effective,  and  is  to  be  preferred  to  the 
bath  where  the  patient  is  weak.  Place  a  rubber  sheet  on  the 
bed ;  over  this  place  an  old  blanket.  Wet  a  sheet  or  a  very 
large  Turkish  towel  in  water,  the  temperature  of  which  may 
be  from  70°  to  90°  F.  Wrap  the  patient  up  in  this  and 
fold  the  blanket  over  the  patient.  Place  cold  compresses 
upon  the  head.  Cold  water  may  be  poured  ou  the  sheet  from 
time  to  time,  or  if  the  temperature  is  high,  ice  may  be  rubbed 
over  the  sheet.  This  may  be  continued  from  five  to  thirty 
minutes.  Cold  packs  are  useful  in  high,  temperature,  ner- 
vousness from  fever  or  other  causes,  and  often  induce  sleep. 

Cold  Sponge. — Place  a  rubber  sheet  on  the  bed  and  a 
sheet  or  old  blanket  upon  this,  and  put  the  patient  upon 
them.  Sponge  with  water  the  temperature  of  which  is  from 
70°  to  90°  F.  Colder  water  may  be  used  in  some  cases. 
After  sponging  a  few  minutes  take  the  temperature  to  note 
the  effect  of  the  cold.     (See  Cold  Baths.) 

Cold  Bath. — These  are  very  useful  in  treating  sick  chil- 
dren, as  a  child  can  be  tubbed  much  easier  thau  an  adult. 
In  many  cases  of  high  fever  this  is  the  only  means  to  control 
it.  If  the  bath  causes  great  prostration  or  nervousness  it  is 
better  to  use  some  other  form  of  cold.  The  water  may  vary 
from  70°  to  95°  F.,  according  to  circumstances.  It  may  be 
31 


482  DISEASES   OF  INFANTS  AND   CHILDREN. 

used  warm  at  first  and  reduced  after  the  child  is  accustomed 
to  it.  This  is  done  by  adding  cold  water  or  placing  a  piece 
of  ice  in  the  tub.  If  the  child  is  apprehensive,  place  him  upon 
a  blanket  or  a  sheet  put  over  the  tub  and  allow  him  to  sink 
into  the  water. 

Take  the  temperature  from  time  to  time,  and  do  not  reduce 
too  much,  as  the  temperature  continues  to  fall  after  the  child 
is  taken  from  the  bath.  If  the  temperature  is  reduced  to 
normal  in  the  bath,  it  may  become  subnormal  afterwards  and 
cause  collapse.  A  reduction  of  100°  to  101°  F.  is  sufficient 
in  most  instances. 

After  the  bath,  dry  rapidly  and  wrap  the  child  in  bed. 
If  there  is  great  prostration,  give  a  small  dose  of  wine  or 
other  stimulant. 

Evaporating  Bath. — This  is  sometimes  used,  but  has  cer- 
tain objections.  The  child  is  covered  with  a  wet  sheet  and 
the  water  allowed  to  evaporate.  The  sheet  is  wet  from  time 
to  time.  Sometimes  tlie  patient  is  placed  in  the  draft  from 
an  electric  fan  to  facilitate  evaporation. 

Certain  therapeutic  measures  of  a  general  nature 
are  very  important  in  the  treatment  of  disease  in  infancy  and 
childhood,  and  these  are  often  neglected.  If  the  child  has 
fever  it  should  be  kept  in  bed,  and  in  all  cases  the  child 
should  be  kept  quiet  and  not  disturbed  unnecessarily  ;  it 
should  not  have  exciting  games  or  visitors.  Rest  in  bed  and 
quiet  are  the  greatest  factors  in  curing  many  conditions  in 
which  there  is  a  large  nervous  element.  It  is  particularly 
needful  in  the  present  day.  Upset  conditions  resulting  from 
overwork  at  school,  too  much  excitement,  and  too  little  rest 
are  easily  cured  in  this  manner.  Fresh  air  is  a  second  factor 
on  which  too  much  stress  cannot  be  laid.  Care  should  be 
taken,  however,  to  have  the  child  adequately  protected  from 
cold  if  necessary.  Changes  in  the.  climate  are  of  great  service 
and  often  utilized  too  late.  They  are  of  particular  value  in 
tuberculosis  and  protracted  cases  of  bronchitis,  bronchopneu- 
monia, intestinal  indigestion,  and  ileocolitis.  Massage  is  use- 
ful, especially  in  children  taking  the  rest  cure,  for  keeping  up 


THERAPEUTICS  FOR  INFANTS  AND   CHILDREN    483 

the  nutrition  of  paralyzed  limbs,  chronic  constipation,  for 
stimulating  nutrition  in  cases  of  marasmus  and  malnutrition, 
and  other  conditions  too  numerous  to  mention.  Good  nurs- 
ing is  of  inestimable  value,  and  a  well-trained,  tactful  nurse 
is  an  asset  in  the  treatment  of  all  the  severer  diseases  which 
is  hard  to  overestimate.  The  nurse  should  be  instructed  to 
care  especially  for  the  comfort  of  the  child,  a  point  of  greatest 
importance  in  the  treatment  of  bed-ridden  children.  The 
physician  and  nurse  should  both  pay  careful  attention  to  the 
treatment  of  minor  symptoms,  often  of  little  importance  when 
compared  to  the  real  disease,  but  very  annoying  and  wearing 
to  the  patient. 

Directions  in  regard  to  giving  drugs  and  food  and  the  use 
of  other  therapeutic  measures  should  always  be  written  and 
explained  to  the  mother  or  nurse.  By  so  doing  many  mis- 
takes are  avoided. 

Anesthetics. — Under  ordinary  circumstances  ether  is 
always  to  be  preferred.  Sometimes  it  is  advisable,  if  a  skilled 
anesthetist,  to  administer  nitrous  oxid  or  ethyl  chlorid 
before  beginning  the  ether.  Children  do  not  bear  nitrous 
oxid  well,  as  a  rule,  as  it  is  liable  to  cause  convulsions. 
Ethyl  chlorid  requires  too  much  care  in  its  administration 
for  ordinary  use.  Chloroform  should  be  chosen  when  there 
is  bronchitis,  pneumonia,  pleurisy,  or  diseases  of  the  larynx. 
It  is  very  dangerous  and  often  causes  sudden  death  in  the  so- 
called  Lymphatic  type. 

Antipyretic  Drugs. — These  are  to  be  prescribed  for  the 
nervous  symptoms  accompanying  fever  rather  than  for  the 
high  temperature.  The  temperature  is,  as  a  rule,  better  con- 
trolled by  cold.  Acetanilid  is  depressing  and  should  not  be 
given  to  children.  Antipyrin  is  of  the  greatest  service,  as  it 
relieves  pain  and  allays  nervousness.  It  has  a  bitter  taste, 
which  is  disguised  by  the  syrup  of  orange. 

R  Antipyrin 1  (gr.  xvi) ; 

Syrup  of  orange 60  (Jij). — M. 

Sig. — A  teaspoonful  every  two  horn's. 

Children   bear  antipyrin   well,  and  it  may  be  given  in 


484 


DISEASES  OF  INFANTS  AND   CHILDREN. 


1-gr.  closes  to  a  child  one  year  old,  and  in  2-gr.  doses  at 
three  or  four  years.  Some  authors  estimate  the  dose  at  J  gr. 
for  each  month  of  the  child's  age.  This  answers  for  young 
infants,  but  later  results  in  too  large  doses.  Combined  with 
small  doses  of  codein  it  is  a  good  hypnotic,  analgesic,  cough 
sedative,  and  antispasmodic. 

R     Codein  sulphate 0.03  (gr.  £) ; 

Antipyrin 1.0     (gr.  xvi) ; 

Syrup  of  orange      60.0     (^ij). — M. 

Sig. — A  teaspoonful  every  two  hours  as  needed.  (For  a  child  of  two  years.) 

The  above  is  better  than  morphia  for  children  and  is  one 
of  the  most  useful  prescriptions  in  pediatric  practice.  Anti- 
pyrin sometimes  causes  a  scarlatiniform  rash. 

Phenacetin  may  be  used.  It  is  insoluble  and  is  tasteless. 
It  is  best  given  in  powders  with  a  little  sugar. 

Opiates. — Opium  and  its  derivatives  should  be  used 
sparingly  in  early  life ;  for,  while  they  are  among  the  most 
valuable  drugs,  they  are  frequently  not  well  borne.  Opium 
should  never  be  used  in  diarrhea  until  the  bowel  is  thor- 
oughly cleansed.  In  the  infectious  forms  it  should  always  be 
used  with  great  caution.  It  is  used  to  relieve  pain  and  to 
lessen  the  number  of  stools.  After  two  or  three  years  of 
age  opium  may  be  used  for  the  same  indications  as  in  adults, 
but  in  proportionately  much  smaller  doses.  Where  possible 
it  is  better  to  resort  to  other  drugs.  Codein  is  of  especial 
value  during  childhood.  Holt  gives  the  following  table  of 
the  initial  doses  of  the  various  preparations.  These  may  be 
repeated  at  intervals  of  several  hours  as  needed  : 


Paregoric 

Deodorized  tincture . 
Dover's  powder     .    . 

Morphin 

Codein 


1  month. 

3  months. 

1  year. 

mi 

mn 

mv-x 

1TIA 

m* 

m  Wo 

gr-  2V 

gr.  tu 

gr-  H 

gr*  To"o"o~ 

gr-  *fa 

gr.  ?hs 

gr.  ¥o"o 

gr.  sfo 

gr.  *V 

5  years. 


m  xxx-xl 

m  ij-iij 

gr-  ij-iij 

gr-  3V-2V 
gr-  tW 


THERAPEUTICS  FOB- INFANTS  AND   CHILDREN.    485 

Somnifacients. — Chloral  hydrate  is  a  very  efficient 
drug  in  producing  sleep  and  allaying  spasms.  Its  greatest 
use  is  during  or  alter  convulsions.  It  may  be  administered 
by  the  rectum  where  possible  or  else  by  the  mouth.  It  some- 
times causes  vomiting.  1  gr.  may  be  given  to  a  child  of  one 
month  of  age,  2  gr.  at  six  months,  3  gr.  at  nine  months,  and 
4  gr.  at  one  year.  1  or  2  gr.  often  suffice  even  at  this  age 
and  should  be  tried.  It  may  be  combined  with  bromids  to 
great  advantage. 

R     Chloral  hydrate 0.5  (gr.  viii) ; 

Sodium  broruid 1.0  (gr.  xvi)  ; 

Syrup  of  orange 60.0  ( 3 i j )  - — M. 

Sig. — A  teaspoonful  at  a  dose  as  a  sedative.  Repeat  in  an  hour  if 
necessary. 

For  convulsions  use  larger  doses  and  repeat  oftener. 

Urethan  may  be  used  in  the  same  manner  as  chloral  and 
m  the  same  doses. 

Veronal  is  a  good  hypnotic  and  may  be  used  in  doses  of 
from  1  to  2  gr.  It  is  best  prescribed  in  powder  and  given 
stirred  up  in  a  spoonful  of  water  or  milk. 

Trional  is  sometimes  used  in  doses  of  1  gr.  or  a  little 
less  for  each  year  of  the  child's  age.  Prescribe  in  powders 
to  be  stirred  into  water  or  milk. 

Sulphonal  may  be  used  in  doses  of  from  1  to  8  gr.  It 
takes  several  hours  before  the  effect  is  produced. 

Bromids. — These  are  useful  in  nervousness,  after  convul- 
sions, and  in  epilepsy.  Small  doses  often  produce  sleep  in 
children.  Sodium  bromid  is  to  be  preferred  as  being  less 
irritating  than  either  potassium  or  ammonium  bromid.  Com- 
binations of  all  three  are  frequently  advised.  Bromids  are 
best  given  in  essence  of  pepsin  or  in  the  aromatic  waters,  as 
peppermint  water. 

Bromipin  (10  percent,  brominized  sesame  oil)  is  frequently 
used  in  epilepsy  where  it  is  to  be  continued  for  a  long  time. 
It  may  be  given  in  from  J  to  1  dr.  doses  three  or  four  times 
a  day. 

Stimulants. — Alcohol. — This  is  a  most  useful  drug 
when  given  in  proper-sized  doses,     It  is  also  of  value  as  a 


486  DISEASES  OF  INFANTS  AND  CHILDREN. 

food  in  long- continued  fevers.  It  should  not  be  given  in 
high  sthenic  fevers  where  there  is  a  full-bounding  pulse 
and  a  flushed  face. 

In  infants  pure  old  whisky  diluted  at  least  eight  times 
with  water  is  the  best.  Pure  brandy  may  be  substituted. 
In  vomiting,  teaspoonful  doses  of  iced  champagne  are  some- 
times useful.  In  older  children  sherry  wine  or  other  wines 
may  be  used  if  desired,  or  the  spirits  may  be  continued  with 
a  bitter  tonic. 

The  dosage  varies  with  the  effect  produced.  The  doses 
should  be  small  and  repeated  often.  Large  doses  may  cause 
mental  symptoms  which  are  most  undesirable.  If  the  odor 
of  alcohol  is  apparent  on  the  breath,  too  much  is  being  given. 
From  5  to  30  drops  of  whisky  may  be  given  at  a  dose, 
according  to  the  age  and  condition  of  the  child. 

5  or  10  drops  of  gin  in  a  little  sweetened  water  is  a 
good  carminative  in  infantile  colic. 

The  time-honored  brandy-and-egg  mixture  of  Stokes  is  a 
useful  means  of  combining  food  and  a  stimulant.  The  fol- 
lowing is  the  formula  as  modified  for  infants  by  Louis  Starr : 

Yolk  of  a  raw  egg  ;  10  drops  of  brandy  ;  1  teaspoonful  of 
cinnamon  water ;  1  coffeespoonful  of  white  sugar.  Beat 
together  into  a  smooth  mass. 

Strychnin. — This  is  useful  as  a  tonic  and  as  a  stimulant. 
Nux  vomica  is  much  used  as  a  bitter  tonic  for  older  children. 
Strychnin  is  best  given  in  small  doses  well  diluted  with 
water.  From  T-^-  to  -^  gr.  may  be  given  at  a  time, 
according  to  the  age  of  the  child.  If  it  causes  twitching  it 
should  be  stopped  and  smaller  doses  given  subsequently.  In 
giving  stimulants  it  is  well  to  alternate  whisky  and  strych- 
nin at  from  two-  to  four-hour  intervals.  Do  not  stimulate 
too  early.  Do  not  use  too  large  doses  of  stimulants.  Re- 
member, stimulation  is  usually  overdone. 

Merck's  digitalin  is  a  useful  heart  stimulant.  It  may  be 
given  in  doses  of  from  T^  to  -^  gr.,  according  to  the 
age  of  the  patient.  It  is  non-cumulative  in  its  action.  Do 
not  confuse  this  with  the  ordinary  digitalin. 

Camphor. — This  is  much  used  in  Germany  as  a  stimulant. 


THERAPEUTICS  FOR   INFANTS  AND   CHILDREN.    487 

The  dose  is  from  \  to  3  gr.  It  is  usually  given  hypo- 
dermatically  in  10  per  cent,  solution  in  sterilized  oil. 

Digitalis. — This  is  useful  in  uncompensated  heart  disease. 
In  aortic  disease  it  should  not  be  used  except  as  the  last 
resort.      The  infusion  is  frequently  used  as  a  diuretic. 

Belladonna  and  Atropin. — These  are  both  well  borne  in 
early  life.  They  are  used  as  stimulants  sometimes,  but  espe- 
cially to  allay  irritability,  as  in  whooping-cough.  They  arc 
used  in  enuresis.      Large  doses  are  advised  in  intussusception. 

The  dose  should  be  small  at  the  outset,  and  increased  until 
slight  flushing  of  the  face  is  observed,  twenty  or  thirty 
minutes  after  administration.  Blondes  require  less  than 
brunettes.  Overdoses  cause  a  red  rash,  dry  throat,  and 
mydriasis.     Too  large  doses  may  cause  delirium. 

The  dose  of  the  tincture  is  from  1  to  10  drops  ;  of  the 
extract,  -^  gr.  for  one  year,  -^  gr.  for  two  years,  -^  gr.  for 
three  years,  etc. 

Atropin  is  best  given  in  solution.  Add  1  gr.  to  2  oz.  of 
water ;  each  drop  represents  1  ^0Q  gr.,  and  1  drop  may  be 
given  for  each  year  of  the  child's  age,  and  the  dose  increased 
gradually.  Do  not  prescribe  strong  solutions  of  atropin 
where  the  people  are  ignorant  or  careless. 

Hyoscyamus. — Tincture  dose,  1  to  5  min.  This  is  a  useful 
antispasmodic  in  cystitis,  vesical  spasm,  and  whooping  cough. 

R  Tincture  of  hyoscyamus 2  (^ss) ; 

Potassium  citrate 4  f.^j)  ; 

Water q.  s.  ad  120  (Jiv).— M. 

Sig. — Teaspoonful  in  water  every  two  hours.     (Two  years.) 

The  fluid  extract,  dose  J-  to  -J-  min.,  is  frequently  used,  in 
chronic  constipation,  combined  with  nux  vomica  and  other 
drugs. 

Tonics. — The  most  important  of  these  are  iron,  cod-liver 
oil,  and  the  bitter  tonics,  such  as  nux  vomica  and  quinin. 

Cod-liver  oil  may  be  given  plain  in  doses  of  J  a  tea- 
spoonful  to  a  tablespoonful.  Small  doses  are  to  be  preferred, 
as  they  do  not  upset  the  stomach.  A  drop  or  two  of  oil  of 
wiutergreen  added  to  the  bottle  of  oil  makes  it  more  palatable 
for  some  children.     Do  not  give  cod-liver  oil  in  very  hot 


488  DISEASES   OF  INFANTS  AND   CHILDREN. 

weather.     See  that  the  oil  is  fresh.      Emulsions  of  cod-liver 
oil  may  be  used  when  the  plain  oil  is  not  well  borne. 

R  Cod-liver  oil 60.0  ffij); 

Dry  extract  of  malt 15.5  (^iv)  ; 

Calcium  hypopkosphite, 

Sodium  hypopkosphite aa      1.0  (gr.  xvj); 

Potassium  kypophosphite 0.5  (gr.  viij) ; 

Glycerin       . 7.5  (gij); 

Pulverized  acacia 15.0  (^iv); 

Water q.  s.  ad  120.0  (t^iv).—M. 

Sig. — Teaspoonful  three  times  a  day. .  (Louis  Starr.) 

Iron. — The  syrup  of  the  iodid  of  iron  is  one  of  the  best 
preparations  for  use  in  childhood.  From  5  to  40  drops  may 
be  given  at  a  dose  three  or  four  times  a  day.  The  astringent 
iron  preparations  should  not  be  used  in  infancy,  and  but 
little  during  later  childhood. 

The  solution  of  iron  and  manganese  peptonate,  although  not 
officinal,  is  an  excellent  way  in  which  to  prescribe  iron.  The 
dose  for  infants  and  young  children  is  from  10  drops  to  a 
teaspoonful. 

Ferrosomatose  in  doses  of  from  5  to  10  gr.  may  be  added 
to  milk  or  broths. 

Reduced  iron,  lactated  iron,  and  the  saccharated  carbonate 
may  all  be  prescribed  in  from  J-  to  2-gr.  doses  in  powders. 

The  bitter  wine  of  iron  is  frequently  prescribed — it  may  be 
advantageously  added  to  an  aromatic. 

Arsenic. — This  is  a  valuable  tonic  in  anemic  and  other 
conditions.  Fowler's  solution  (liquor  potassae  arsenitis)  is 
most  frequently  used  in  doses  of  from  1  to  10  drops  three 
times  a  clay.  Arsenious  acid  in  doses  of  ^-q-  gr.  or  less  is 
often  prescribed. 

Alteratives. — Mercury. — This  is  most  frequently  used 
as  a  purgative  in  the  form  of  calomel.  Tablet  triturates, 
with  or  without  bicarbonate  of  soda,  are  generally  employed. 
It  is  best  given  in  doses  of  y1-^  gr.,  repeated  every  half  hour 
or  every  hour,  and  followed  in  older  children  by  a  saline  if 
necessary. 

Mercury  with  chalk  is  often  used  in  doses  of  from  y1^  to 

1  gr. 


THERAPEUTICS  FOR  INFANTS  AND   CHILDREN     489 

In  syphilis  calomel  (y1^-  gr.),  mercury  with  chalk  (1  gr.),  or 
bichlorid  (y-J-y  gr.),  given  three  or  four  times  a  day,  are  most 
frequently  used.  Mercurial  ointment  is  used  externally  once 
or  twice  daily. 

In  late  syphilis,  mercury  and  the  iodid  of  potassium  may 
often  be  advantageously  combined  as  follows  : 

R  Bichlorid  of  mercury 0.03  (gr.  ss)  ; 

Iodid  of  potassium 4.0    (3J); 

Compound  syrup  of  sarsaparilla     ....    60.0    (^ij); 

Water q.  s.  ad  120.0    (giv).— M. 

Sig. — Teaspoonful  in  water  four  times  a  day. 

Iodin. — This  is  of  great  value  in  late  syphilis  and  in 
strumous  conditions.  Sodium  or  potassium  iodid  are  the 
most  frequently  used  preparations.  The  former  is  said  to  be 
less  irritating  to  the  stomach.  They  are  best  given  in  essence 
of  pepsin.  The  dosage  varies  from  5  gr.  up  to  1  dr.  or 
more. 

Iodin  ointment  is  frequently  used  externally. 

R  Iodin 0.06  (gr.j); 

Iodid  of  potassium     ....  ....    4.0    (3J)> 

Vaselin 30.0    (^j). 

M.  and  make  into  an  ointment. 

Iodoglycerin  is  frequently  used  as  an  application  to  mucous 
membranes. 

R  Iodin     .    .    . 0.06  (gr.j); 

Iodid  of  potassium 1.3    (gr.  xx)  ; 

Glycerin 30.0    (|j).— M. 

External  Use. — Potassium  Chlorate. — Dose,  J  to  2  gr. 
This  may  be  given  in  a  saturated  solution,  of  which  each 
teaspoonful  represents  4  gr.  It  should  be  well  diluted.  It 
is  almost  a  specific  for  ulcerative  stomatitis,  and  is  useful  in 
follicular  tonsillitis.  It  may  be  given  alone  or  combined 
with  iron. 

R  Potassium  chlorate 1.5  (gr.  xxiv) ; 

Syrup  of  orange 30.0  (j§j); 

Water q.  s.  ad  90.0  (Jiij).— M. 

Sig. — Teaspoonful  every  two  or  three  hours.     (Two  years),  or 


490  DISEASES   OE  INFANTS  AND   CHILDREN. 

R  Potassium  chlorate 1.5  (gr.  xxiv)  ; 

Tincture  of  the  chlorid  of  iron    ....    2.5  (n\,xxxvj) ; 

Syrup  of  ginger 15.5  Qfss) ; 

Water q.  s.  ad  90.0  siij).— M. 

Sig. — A  teaspoonful  in  water  every  two  hours.  (Louis  Starr.) 

Stomachics.  —Aromatic  and  bitter  tonics  are  often  used 
either  to  excite  an  appetite  and  for  their  tonic  effect  or  to 
allay  an  irritable  stomach.  Pepsin  is  frequently  added  to 
such  mixtures,  or  they  may  be  combined  with  alkalies. 

R  Tincture  of  nux  vomica 1.5  (rr^xxiv)  ; 

Essence  of  pepsin  (Fairchild's)  ....  15.5  (^iv); 

Aromatic  elixir q.  s.  ad  90.0  (^iij). — M. 

Sig. — Teaspoonful  in  water  three  times  a  day. 

R  Tincture  of  nux  vomica 2.0  (^ss); 

Dilute  hydrochloric  acid 8.0 " ( 3 i j ) ; 

Essence  of  pepsin 15.5  (,^iv) ; 

Aromatic  elixir q.  s.  ad  90.0  (,^iij). — M. 

Sig. — Teaspoonful  in  water  three  times  a  day. 

The  aromatic  waters,  as  anise  water,  cinnamon  water,  fennel 
water,  or  peppermint  water,  are  frequently  used  to  allay  pain 
in  the  stomach  and  to  facilitate  the  expulsion  of  gas.  The 
dose  is  from  10  ruin,  to  1  dr.  They  are  much  used  as 
vehicles  for  other  drugs. 

An  aromatic  water  and  an  alkali  are  very  efficacious  in 
checking  vomiting  and  allaying  nausea,  as 

R  Lime  water, 

Cinnamon  water  . aa  60  (,^ij). — M. 

Sig. — A  teaspoonful  every  fifteen  or  thirty  minutes  as  needed. 

Dr.  Louis  Starr  recommends  effervescing  draughts  for  the 
same  purpose,  especially  where  there  is  fever,  as 

Solution  No.  1 : 

R  Citric  acid 5.5  (.^iss) ; 

Water 90.0  |iij).— M. 

Solution  No.  2 : 

R  Potassium  bicarbonate 4.0  (3J); 

Water 90.0  (ijiij).— M. 

Sig. — Mix  a  teaspoonful  of  each  in  a  glass  and  drink  while  it  effervesces 
Dilute  with  water  if  desired. 


THERAPEUTICS  FOR  INFANTS  AND  CHILDREN.    491 

Another  prescription  of  use  in  chronic  vomiting  in  in- 
fants is 

&   Solution  of  potassium  arsenite  (Fowler's 

soution) 0.75  (TTLxij); 

Sodium  bicarbonate 1.50  (gr.  xxiv) ; 

Peppermint  water 90.0    (jfiij). — M. 

Sig. —  One  teaspoonful  three  times  a  day. 

Cerium  oxalate  is  frequently  prescribed  for  vomiting.  The 
dose  is  from  J  to  3  gr.,  given  in  powders. 

Digestants. — Pepsin. — This  is  frequently  prescribed 
either  in  scale  pepsin  (dose,  1  to  2  gr.)  or  in  solutions,  as  the 
esseuce  of  pepsin,  which  is  given  in  doses  of  from  10  min. 
to  1  dr. 

Taka-diastase  is  useful  in  starch  indigestions.  To  chil- 
dren it  is  best  given  in  solution  in  doses  of  15  min.  to  1  dr. 

Cathartics. — There  are  a  great  many  drugs  under  this 
head.     The  most  useful  are  the  following  : 

Castor  Oil. — Dose,  1  dr.  to  1  oz.  Castor  oil  is  one  of  the 
most  valuable  drugs  we  have.  In  almost  every  acute  illness 
it  is  desirable  to  thoroughly  empty  the  bowels  at  the  start. 
Castor  oil  does  this  effectually  and  is  not  irritating  to  the  bowel. 
It  may  be  diluted  with  olive  oil  for  very  young  infants.  Ritter 
gives  the  following  formula  for  palatable  castor  oil : 

£    Saccharini 0.12  (gr.  ij)  ; 

Olei  menthse  piperita? 0.30  (gtt.  v) ; 

Alcoholis,  q.  s.  M.  fiat  sol.  et  adde ; 

Oleiricini 240.      (^viij).— M. 

Calomel  (see  Mercury). — One  of  the  most  valuable  cathar- 
tics, especially  in  cases  where  there  is  nausea  and  vomiting. 

Magnesia. — This  is  frequently  used.  Calcined  magnesia 
may  be  given  in  doses  of  J  of  a  teaspoonful.  In  smaller 
doses  it  is  useful  as  an  antacid. 

Milk  of  Magnesia  (Phillips). — This  is  useful  as  antacid 
and  laxative.     The  dose  is  from  1  to  4  teaspoonfuls. 

Sulphate  of  Magnesia  {Epsom  Salts). — This  is  a  useful 
saline  for  older  children.  It  may  be  given  in  doses  of  J  dr. 
to  J  oz.     The  following  is  a  valuable  hospital  mixture  : 


492  DISEASES  OE  INEANTS  AND   CHILDREN. 

R   Magnesium  sulphate,  q.  s.,  to  make  saturated  solution. 

Aromatic  sulphuric  acid 4.0  (^j); 

Water 120.0  (^iv).— M. 

Sig. — One  to  two  teaspoonfuls  in  a  little  water.   Kepeat  m  an  hour  or  two 
if  necessary. 

Citrate  of  Magnesia. — This  is  an  effervescent  solution  of 
pleasant  taste.  It  may  be  given  to  children  in  doses  of  from 
1  tablespoonful  to  1  wineglassful. 

Rhubarb. — This  is  a  useful  stomachic  and  laxative.  It  is 
of  especial  value  in  mild  diarrhea.  The  aromatic  syrup  is 
the  Best  preparation  for  children,  and  can  be  given  in  doses 
of  J  to  1  dr.  The  syrup  is  sometimes  used  in  similar  doses. 
The  rhubarb  and  soda  mixture  is  used  in  doses  of  J  to  2  dr. 

R   Sodium  bicarbonate 1.5  (gr.  xxiv) ; 

Aromatic  syrup  of  rhubarb 15.5  (,^ss) ; 

Simple  syrup 30.0  (jfj); 

Peppermint  water q.  s.  ad  90.0  (|iij).— M. 

Sig. — A  teaspoonful  at  a  dose.     (At  two  years. ) 

Cascara  Sagrada. — This  is  a  useful  laxative.  The  dose 
of  the  fluid  extract  is  from  5  to  15  drops.  It  is  often  pre- 
scribed in  equal  parts  of  simple  syrup  and  water.  The 
aromatic  extract  in  doses  of  from  J  to  1  dr.  may  be  pre- 
scribed. Preparations  of  cascara  are  now  made  in  palatable 
form  by  the  manufacturing  chemists. 

Manna. — This  is  pleasant  to  taste  and  useful.  From  half 
to  a  teaspoonful  may  be  given  to  the  child  to  eat. 

The  following  is  a  useful  laxative  for  infants  : 

R     Manna, 

Magnesium  carbonate aa    8.0  (,"ij); 

Fluid  extract  of  senna 15.5  (^ss); 

Simple  syrup 30.0  yf  j)  ; 

Peppermint  water q.  s.  ad.  90.0  (^iij). — M. 

Sig. — One  teaspoonful  two  or  three  times  a  day.  ( Louis  Starr.  ) 

Senna. — This  is  very  useful.  Senna  leaves  may  be  added 
to  stewed  prunes  and  make  a  pleasant  laxative.  There  is  a 
confection  of  senna  containing  tamarinds  and  senna  (dose, 
J-l  dr.),  and  it  is  also  one  of  the  ingredients  of  compound 
licorice  powder.  The  syrup  of  senna  is  usually  given  to 
children  in  doses  of  5  drops  to  1  dr. 

Diuretics. — These  are  useful  in  fevers  and  to  assist  in 


THERAPEUTICS  J"i:   INFANTS  AND   CHILDREN.      193 

the  absorption  of  serous  effusions.  Mixtures  of 
calomel  and  digitalis  and  squills  are  useful  in  the  edema  due 
to  heart  disease.  The  infusion  of  digitalis  is  also  of  value 
in  such  eases. 

Potassium  Acetate. — Dose,  3  to  5  gr.  Usually  given  in 
simple  syrup  or  syrup  of  lemon  and  water. 

Potassium  Bitartrate  [Cream  of  Tartar). — Dose,  1  to  10 
gr. ;  in  larger  doses  is  laxative.  Is  useful  in  fevers  as  the 
Imperial  Drink,  which  is  made  by  pouring  a  pint  of  boiling 
water  over  a  teaspoonful  of  cream  of  tartar  and  adding  the 
juice  of  a  lemon.     It  is  given  cold  as  a  beverage. 

Solution  of  Ammonium  Acetate  [Liquor  Ammonii  Acdatis, 
Spirit  of  Jlindererus). — Dose,  5  drops  to  1  dr.  This  is  fre- 
quently used  as  a  fever  mixture. 

Iron  and  Ammonium  Acetate  Mixture  (Basham's  Mixture). 
— This  is  frequently  used  as  a  diuretic  and  tonic  in  chronic 
nephritis,  and  where  it  is  desirable  to  produce  diuresis  in 
anemic  subjects.     For  children  tbe  dose  is  from  J  to  1  dr. 

Diuretin  (Sodiotheobroiaiii  Salicylate). — This  is  given  in 
doses  of  from  2  to  10  gr.  It  usually  produces  free  diuresis. 
It  is  best  given  in  powders  or  capsules,  followed  by  water. 

Diaphoretics. — Sweet  spirit  of  niter  is  the  most  fre- 
quently used  diaphoretic.  It  is  usually  prescribed  in  doses 
of  two  minims  to  half  a  dram  combined  with  simple  syrup  or 
some  aromatic  water.  It  is  frequently  used  in  fever  mix- 
tures. 

Spirit  of  mindererus  is  also  used  as  a  diaphoretic  in  fever 
mixtures. 

Expectorants  and  Cough  Mixtures. — Ipecacuanha. 
— This  is  of  great  service  in  increasing  and  thinning  the 
bronchial  secretions.  In  small  doses  it  forms  part  of  many 
cough  mixtures.  The  syrup  is  usually  given  in  doses  of 
1  to  5  drops  and  the  wine  in  J-  to  2-drop  doses.  Larger 
quantities  produce  nausea  and  vomiting.  Teaspoonful  doses 
repeated  every  fifteen  minutes  until  vomiting  occurs  may  be 
used  to  empty  an  overloaded  stomach  or  to  afford  relief  in 
bronchitis  when  the  mucus  is  filling  up  the  tubes  and  cannot 
be  coughed  up. 


494  DISEASES  OE  INFANTS  AND   CHILDREN. 

Dover's  Powder  is  frequently  used.  (See  Opium.) 
Antimony  and  Potassium  Tartrate  (Tartar  Emetic). — This 
is  used  in  bronchitis  and  catarrhal  spasm  of  the  larynx.  It 
is  best  given  in  tablet  form  in  doses  of  -^q  *°  Tiro  °^  a 
grain.  It  may  be  combined  with  an  equal  quantity  of 
ipecac. 

R  Antimony  and  potassium  tartrate    .    .    .    0.0016  (gr.  ^q)  ; 

Solution  of  ammonium  acetate 15.5        (^ss); 

Syrup  of  tolu 30.0        (|j); 

Water q.  s.  ad.  90.0        (jfiij).— -M. 

Sig. — One  teaspoonful  every  three  hours.     (Four  to  six  years.) 

Ammonium  Chlorid. — This  is  one  of  the  best  stimulating 
expectorants.  About  J-  gr.  may  be  given  for  each  year  of  the 
child's  age.  It  is  frequently  added  to  cough  mixtures,  par- 
ticularly to  the  compound  licorice  mixture  (brown  mixture). 

Senega. — This  is  a  stimulating  expectorant  of  especial 
value  in  the  later  stages  of  bronchitis  where  difficulty  is  ex- 
perienced in  raising  the  large  quantities  of  secretion.  The 
syrup  is  prescribed  in  doses  of  5  to  10  min.  or  more  and  the 
fluid  extract  in  doses  of  1  to  5  min. 

Balsam  of  Tolu. — This  is  used  in  the  form  of  the  syrup 
of  tolu  and  makes  a  pleasant  vehicle  for  other  expectorants. 

Squills. — This  is  one  of  the  most  valuable  expectorants 
and  is  of  especial  value  after  the  first  stage  of  bronchitis. 
The  syrup  is  most  frequently  used  in  2-  to  10-drop  doses. 
The  time-honored  Jackson  mixture  is  an  efficient  cough  mix- 
ture for  young  children. 

R   Syrup  of  squills 8  f.^ij); 

Oil  of  sweet  almonds 15  ( ^ss) ; 

Mucilage  of  acacia 15  (.5ss)  ; 

Syrup  of  tolu q.  s.  ad.  120  (giv).—  M. 

Sig. — Shake  well.  One-half  to  one  teaspoonful  every  two  or  three  hours. 
(One  to  three  years.) 

The  compound  syrup  of  squills  contains  f-  gr.  of  tartar 
emetic  to  each  J  oz.,  and  should  be  used  with  caution,  if  at 
all,  for  young  children. 

Terpin  Hydrate. — Dose,  1  to  5  gr.  Useful  as  an  expec- 
torant in  bronchitis.  It  is  frequently  combined  with  heroin 
in  an  elixir. 


THERAPEUTICS  FOR  INFANTS  AND   CHILDREN.     495 

Licorice. — This  is  used  as  a  vehicle  for  quinin,  the  elixir 
being  the  best  preparation.  Combined  with  paregoric,  sij, 
wine  of  antimony,  3J,  and  sweet  spirits  of  niter,  §ss  to  the 
pint,  it  is  the  compound  licorice  mixture  or  brown  mixture 
frequently  used  for  coughs,  either  alone  or  with  ipecac, 
squills,  ammonium  chlorid,  or  senega.  For  children  it  is 
advisable  to  have  it  made  with  half  the  quantity  of  pare- 
goric. The  dose  is  from  10  drops  to  a  teaspoonful.  The 
compound  licorice  powder  (dose  10  gr.  to  1  dr.)  is  used  as  a 
laxative. 

Creosote. — This  is  a  most  valuable  drug,  and  is  used  in 
bronchitis,  tuberculosis,  bronchiectasis,  pulmonary  gangrene, 
and  also  as  an  intestinal  antiseptic.  It  is  used  as  an  inhala- 
tion (see  Inhalations)  or  internally.  From  J  to  2  drops  are 
given  at  a  dose.  For  internal  use  in  young  children  the 
liquid  beef  peptonoids  with  creosote  is  the  best  preparation  to 
use.     From  10  drops  to  2  dr.  may  be  given  at  a  close. 

Creosote  Carbonate  (Creosotal). — This  is  an  excellent 
preparation,  and  may  be  given  in  place  of  creosote.  It 
rarely  causes  any  disturbance  of  the  stomach.  It  may  be 
given  in  syrup  or  glycerin  and  wTine.  The  dose  is  1  drop 
for  each  year  of  the  child's  age  up  to  ten. 

Guaiacol. — This  is  useful  in  follicular  tonsillitis.  It 
should  be  combined  with  an  equal  part  of  glycerin  and 
applied  directly  into  the  crypts  of  the  tonsil  by  means  of 
cotton  on  a  very  fine-pointed  probe. 

Guaiacol  Carbonate  (Duotal). — This  is  used  in  exactly  the 
same  indications  as  creosote.  It  is  administered  in  powders 
or  in  capsules  for  older  children.     The  dose  is  from  1  to  8  gr. 

Heroin. — This  is  a  useful  cough  sedative,  and  may  be 
used  to  diminish  the  intensity  and  frequency  of  cough  as  well 
as  to  allay  irritability.  It  is  most  useful  in  whooping-cough. 
It  is  best  given  in  an  elixir,  and  may  be  combined  with 
terpin  hydrate.  From  -g-J-g-  to  -^  gr.  at  a  dose.  The  hydro- 
chlorate  is  always  prescribed  when  solutions  are  ordered. 
When  prescribing  with  opium  or  its  derivatives  the  aggre- 
gate should  not  exceed  the  maximum  of  any  single  one  of 
the  group. 


496  DISEASES   OF  INFANTS  AND   CHILDREN. 

Antacids. — This  class  of  drugs  is  much  used  in  infancy 
to  correct  hyperacidity,  allay  colic,  and  in  intestinal  disor- 
ders. Magnesia  is  useful,  especially  when  a  laxative  effect 
is  desired.     (See  same.) 

Sodium  Bicarbonate. — Dose,  1  to  10  gr.  This  is  useful 
alone  or  combined  in  an  aromatic  water  or  with  the  aromatic 
syrup  of  rhubarb. 

Aromatic  Spirit  of  Ammonia. — Dose,  1  to  30  drops.  This 
is  a  useful  stimulating  antacid,  used  with  or  without  other 
alkaline  drugs.     It  is  often  prescribed  for  colic. 

Anthelmintics. — Santonin. — This  is  a  specific  for  ascaris, 
and  may  be  tried  in  obstinate  cases  of  oxyuris.  It  is  best 
given  in  doses  of  \  or  \  gr.,  combined  or  followed  by  calomel. 
Four  to  six  doses  are  usually  prescribed. 

Oleoresin  of  Male  Fern. — This  is  the  best  remedy  for 
tapeworm.  It  is  given  in  \  dr.  or  1  dr.  doses,  either 
in  capsules  or  in  an  aromatic  vehicle.  It  should  be  given 
on  an  empty  stomach,  and  the  intestinal  tract  should  be 
previously  emptied  by  means  of  an  active  cathartic.  A 
cathartic  should  be  used  several  hours  after  the  male  fern 
has  been  given. 

R   Oleoresin  of  male  fern 4  (^j) ; 

Mucilage  of  tragacanth 15  ('^ss) ; 

Syrup  of  ginger 8  (^ij) ; 

Water q.  s.  ad  60  (gij).— M. 

Sig. — Two  tablespoonfuls  at  a  dose. 

Pelletierin  Tannate. — Dose,  2  to  4  gr.  This  is  sold  in 
bottles  containing  the  adult  dose,  about  half  of  which  may 
be  given  to  a  child.  The  same  precautions  should  be  used 
as  for  male  fern.  The  dose  may  be  given  in  sweetened 
water. 

Astringents   and  Drugs  Useful  in   Diarrhea.— 

Chalk  Mixture. — This  is  a  useful  aromatic  antacid  mixture 
containing  chalk,  gum  acacia,  syrup,  and  cinnamon  water.  A 
teaspoonful  or  two  may  be  given  at  a  dose.  It  is  an  excel- 
lent vehicle  for  bismuth. 

Bismuth. — This  is  one  of  the  best  drugs  to  use  in  summer 
diarrhea. 


THERAPEUTICS  FOR  INFANTS  AND   CHILDREN.     497 

Bismuth  Subnitrate. — Dose,  5  to  30  gr.  The  best  bismuth 
preparation.     Give  1  or  2  dr.  a  day. 

R   Bismuth  subnitrate 15  f^ss) ; 

Chalk  mixture 90  (giij).—  M. 

Sig.  —A  teaspoonful  every  two  hours.     (One  year.) 

Bismuth  Subcarbonate. — Dose,  1  to  10  gr.  More  astrin- 
gent than  the  subnitrate. 

]&   Bismuth  subcarbonate 8  (313) ; 

Essence  pepsin 15  (3iv); 

Mucilage  of  acacia 15  (giv)  ; 

Elixir  aromatic q.  s.  ad  90  (^iij). — M. 

Sig. — Shake  well.     Teaspoonful  every  two  hours. 

Bismuth  Salicylate. — Bismuth  subgallate.  Dose,  1  to  5  gr. 
Useful  alone  or  in  combination. 

Beta-naphthol  Bismuth. — Dose,  1  to  3  gr.  A  most  pow- 
erful intestinal  antiseptic.  Very  constipating.  Is  of  marked 
value  when  the  stools  are  loose  and  foul-smelling:. 


'&' 


R   Beta-naphthol  bismuth, 

Bismuth  salicylate aa    1.5  (gr.  xxiv). — M. 

Sig. — Make  twelve  powders.     One  every  two  horn's. 

Tannin. — Various  tannic  acid  derivatives  are  employed 
internally  in  summer  diarrhea  in  doses  from  1  to  10  gr. 
Among  them  are  tanigen,  tannalbin,  tannopin,  and  protan. 
Thev  are  best  administered  in  powder  form. 

Antirheumatic  Remedies. — These  include  the  salicyl 
derivatives  and  similar  preparations.  They  are  used  in 
rheumatism  to  relieve  pain,  and  some  of  them  in  stomach 
and  intestinal  disorders. 

Aspirin. — This  is  an  excellent  substitute  for  sodium  sali- 
cylate, and  is  given  in  the  same  doses.  It  is  best  given  in 
capsules. 

Salicylic  Acid. — Dose,  1  to  5  gr.  This  is  used  in  the 
same  indications  as  sodium  salicylate.  Small  doses  are 
usually  well  borne.  Larger  doses  are  liable  to  cause  vom- 
iting. 

Sodium  Salicylate. — Dose,  1  to  10  gr.  This  is  generally 
used  as  an  antirheumatic  and  to  check  fermentation.     For 

32 


498  DISEASES  OF  INFANTS  AND   CHILDREN. 

the  former  purpose  it  is  given  in  full  doses  ;  for  the  latter 
small  doses  suffice.  It  may  be  given  in  essence  of  pepsin  or 
as  follows  : 

R   Sodium  salicylate 4  (^j)  ; 

Solution  of  ammonium  acetate 15  (J;ss) ; 

Syrup  of  orange 30  ( 5 j ) ; 

Water q.  s.  ad  90  (liij). — M. 

Sig. — Teaspoonful  every  three  hours. 

rx  Sodium  salicylate 1  (gr.  xvi)  ; 

Syrup  of  ginger 8(313); 

Peppermint  water    ......    q.  s.  ad.  60  (  ^ij). — M. 

Sig. — One  teaspoonful  every  two  hours.     (For  a  child  of  two  years.) 

Salol. — Dose,  1  to  5  gr.  This  is  used  in  rheumatism,  in- 
testinal disorders,  and  cystitis.  It  decomposes  in  the  intes- 
tine into  salicylic  acid  and  carbolic  acid.  Small  doses  are 
generally  well  borne,  but  larger  ones  are  liable  to  cause 
vomiting. 

R  Salol 1  (gr.  xvi)  ; 

Aromatic  elixir 8  ( ,^ij )  ; 

Water q.  s.  ad.  60  (^ij).— M. 

Sig. — Teaspoonful  every  two  hours  to  a  child  of  two  years. 

Salophen. — Dose,  1  to  5  gr.  This  is  useful  in  neuralgia 
and  rheumatism. 

Salipyrin. — Dose,  1  to  5  gr ;  used  in  same  indications  as 
salophen. 

Antispasmodics  for  Whooping-cough. — Bella- 
donna, antipyrin,  heroin,  quinin,  and  many  other  drugs  are 
used. 

Bromoform. — Dose,  1  to  5  drops.  Do  not  give  over  15  or 
20  drops  a  day.  A  useful  but  dangerous  drug.  Do  not 
prescribe  it  for  ignorant  or  careless  people,  as  there  is  danger 
of  poisoning  from  overdoses.  In  emulsions  there  is  danger 
that  the  last  dose  will  contain  too  much. 

Urogenital  Antiseptic. — Hexamethylenamin  (Urotro- 
pin). — Dose,  1  to  5  gr.  This  is  best  given  in  water.  It  is 
very  useful  in  all  conditions  in  which  pus  is  found  in  the 
urine. 

To  Render  Urine  Acid. — Monosodium  phosphate,  grains  1 
to  5  or  more  in  sweetened  water.  Benzoic  acid  may  be  used 
in  older  children,  but  it  is  liable  to  cause  nausea. 


THERAPEUTICS  FOR  INFANTS  AND   CHILDREN.  499 

Vasomotor  Stimulant. — Ergot. — The  fluidextract  is 
used  in  doses  of  J  to  2  drops.  It  is  best  given  in  simple 
syrup  and  water.  It  is  useful  in  hemorrhages  and  in  atony 
of  the  intestines. 

Antimalarial  Remedies. — Quinin. — Used  in  malaria 
and  useful  as  a  bitter  tonic.  May  be  given  by  mouth,  rec- 
tum, or  in  extreme  cases  subcutaneously.  Abscesses  are 
liable  to  result  from  the  last-named  procedure. 

Quinin  Tannate. — In  1-gr.  chocolate  tablets.  The  quinin 
is  tasteless,  and  the  tablets  are  readily  taken  by  children. 

Euquinin. — Dose,  1  to  2  gr.     This  is  also  tasteless. 

Syrup  of  cinchona  alkaloids  is  also  tasteless  and  pleasant  to 
take. 

Quinin  Sulphate. — Dose,  -J  gr.  per  month  for  the  first  year ; 
later,  from  1  to  5  gr.  This  may  be  given  in  warm  choco- 
late, in  syrup  of  yerba  santa  or  in  the  elixir  of  licorice.  It 
should  be  added  to  the  vehicle  just  before  taking,  otherwise 
a  bitter  taste  develops. 

Quinin  Suppositories: 

R   Quinin  hydrochlorate 0.4  (gr.  vj)  ; 

Cocoa  butter 12.0  (giij).— M. 

Sig. — Make  12  suppositories.     One  every  six  hours. 

Quinin  hypodermaticaUy  (Bacelli's  formula)  : 

R   Quinin  hydrochlorate     ....    =    ...    1.0    (gr.  xv)  ; 

Sodium  chlorid 0.06  (gr.  j); 

Distilled  water 10.0    (giiss).— M. 

Remedies  for  the  Common  Skin  Diseases. — Acute 
Eczema : 

R  Oxidofzinc      8  (.^ij) ; 

Prepared  calamine      12  (.^iij)  ; 

Lime  water 250  (^viij). — M. 

Sig. — Apply  on  gauze  to  the  affected  part. 

R  Oxid  of  zinc 8  (^ij)  ; 

Prepared  calamine 12  (giij); 

Glycerin 30  (|j)  ; 

Lime  water 60  C.fij); 

Rose  water 250  (;fviij). — M. 

Sig. — Apply  on  gauze  to  the  affected  part.  1  per  cent,  carbolic  acid 
may  be  added  to  either  of  the  above  if  there  is  much  itching. 


500  DISEASES   OF  INFANTS  AND   CHILDREN. 

Lassar's  Paste  : 

R   Salicylic  acid 0.65  (gr.  x) ; 

Oxid  of  zinc, 

Starch aa    8.0    (^ij ) ; 

Vaselin 30.0    (&).—  M. 

Sig. — Apply  several  times  a  day  to  the  affected  part. 

Pick's  Paste  : 

R  Pulverized  tragacanth 4  (gj) ; 

Glycerin       6  (giss) ; 

Bose  water q.s.ad  120  (^iv). — M. 

Sig. — To  this  may  be  added  various  medicaments,  as  zinc  oxid  (40  gr.), 
tar  (10  min.),  or  carbolic  acid  (5  gr.). 

Tar  Ointment: 

R   Ointment  of  liquid  tar 4  (gj ) ; 

Ointment  of  zinc  oxid 30  (^j). — M. 

Sig. — External  use. 

Carbolic  Acid  Ointment  : 

R  Carbolic  acid 0.3  (gr.  v) ; 

Ointment  of  zinc  oxid 30.0  (^j). — M. 

Dusting  Powder : 

R  Zinc  oxid      30  (gj) ; 

Pulverized  starch 120  (^iv). — M. 

Sulphur  and  Salicylic  Acid  Ointment : 

R   Salicylic  acid, 

Sulphur aa    4  (^j) ; 

Vaselin 30  (3j).—  M. 

Sulphur  Ointment: 

R  Sulphur 4  (3j); 

Vaselin 30  (]jjj).— M. 

For  Scabies : 

Sulphur  and  Balsam  of  Peru  Ointment : 

R  Sulphur 4(3J); 

Balsam  of  Peru    . 15  (,^ss) ; 

Vaselin 30  (Jj).— M. 

Resorcin  Ointment : 

R  Kesorcin 0.65  (gr.  x) ; 

Ointment  of  rose  water 30.0    (^j). — M. 

Sig. — Useful  in  seborrhea  and  chronic  eczema. 


THERAPEUTICS  FOR  INFANTS  AND   CHILDREN.     501 

Parasitic  Ointment. — For  children  the  ointment  of 
ammoniated  mercury  (white  precipitate)  is  most  satisfactory. 
It  should  not  be  applied  to  too  large  an  area. 

Ichthyol. — Useful  in  5  to  10  per  cent,  ointment  as  an 
application  for  various  skin  diseases  and  glandular  swellings. 

H    Ichthyol 8  (^ij)  ; 

Ether, 

Glycerin    . aa    15  (Jjss). — M. 

Sig. — Apply  with  a  brush. 

For  i/ocal  Inflammations : 

B   Acetate  of  lead .      2.7  (gr.  xl) ; 

Tincture  of  opium  .    .    .    .    „    ....    .    15.0  (fss); 

Water 250.0  (gviij).— M. 

Sig. — Apply  on  gauze  to  the  affected  part. 

Carron  Oil : 

R   Linseed  oil, 

Lime  water aa  120  (^iv). — M. 

Sig. — Apply  to  affected  part. 

A  good  substitute  for  carron  oil : 

R   Oil  of  sweet  almonds, 

Lime  water aa  120  (^iv). — M. 

Sig. — Useful  in  inflammations  of  the  rectum  and  chafing. 

I^scharotics. — Powdered  burnt  alum  is  a  simple  appli- 
cation to  check  the  growth  of  granulation  tissue  and  also  as 
an  application  in  stomatitis.  It  is  best  applied  with  a  small 
camel?s-hair  pencil.  Silver  nitrate,  generally  used  in  the 
shape  of  a  stick  of  lunar  caustic,  is  useful  to  cauterize  the 
ulcers  in  herpetic  stomatitis,  etc.     It  is  quite  painful. 

Stomach  Washing  (see  Gavage). — The  procedure  is 
the  same  as  for  gavage.  The  stomach  is  filled  with  tepid 
water,  which  is  allowed  to  siphon  off.  This  procedure  is 
repeated  until  the  water  comes  back  perfectly  clear.  If  there 
is  mucus  in  the  stomach  it  is  advisable  to  add  a  teaspoonful 
of  sodium  bicarbonate  to  each  pint  of  water.  Boric  acid  is 
sometimes  used  in  the  same  quantity  where  there  is  fermenta- 
tion. 

Irrigation  of  the  Colon. — This  is  useful  in  diarrheal 


502  DISEASES  OF  INFANTS  AND   CHILD  HEN. 

diseases.  The  infant  is  laid  face  downward  on  the  nurse's 
lap.  A  piece  of  rubber  sheeting  is  arranged  to  carry  the 
water  into  a  slop-jar.  The  floor  should  be  protected  for 
several  feet  by  rubber  sheeting  or  oilcloth.  A  well-oiled 
catheter  is  attached  to  the  nozzle  of  a  fountain  syringe.  The 
catheter  is  introduced  into  the  anus  with  a  slight  twisting 
motion.  As  soon  as  it  is  in  the  rectum  the  water  is  allowed 
to  flow  in  and  the  catheter  inserted  to  nearly  its  full  length. 
It  is  desirable  to  have  it  go  high  up  in  the  colon,  but  it  fre- 
quently doubles  up  in  the  rectum.  The  water  is  allowed  to 
flow  in,  and  when  the  bowel  is  full  it  will  be  ejected  around 
the  catheter.  This  is  continued  until  the  water  returns  clear. 
Before  the  catheter  is  removed  any  astringent  or  other  appli- 
cation, as  desired,  is  introduced  through  it. 

Enemata. — For  the  purpose  of  cleansing  out  the  rectum 
and  lower  bowel,  from  half  a  pint  to  a  pint  and  a  half,  ac- 
cording to  the  size  of  the  child,  of  warm  water  made  soapy 
with  Castile  soap  may  be  allowed  to  flow  into  the  rectum 
from  a  fountain  syringe  or  funnel  and  tube.  The  nozzle 
or  tube  should  be  well  oiled.  The  child  should  be  face 
downward  on  the  nurse's  lap  or  bed.  For  infants,  to  stimu- 
late the  bowel  to  move,  small  rubber  bulb  syringes  holding 
an  ounce  or  two  may  be  used  to  advantage.  The  small  one- 
piece  soft  bulbs  used  for  washing  out  the  ear  are  particularly 
suitable  for  this  purpose.  Normal  salt  solution  is  sometimes 
used,  and  sodium  bicarbonate  (3J  to  Oj)  if  there  is  much 
mucus,  and  boric  acid  (sj  to  Oj)  if  there  is  inflammation  of 
the  bowel.  Quinin  solutions  are  used  in  thread  worms. 
Small  injections  (ass  to  ij)  of  boiled  starch  solution,  to 
which  from  J  to  5  minims,  according  to  age,  of  tincture  of 
opium  have  been  added,  is  useful  in  relieving  tenesmus. 
Fluidextract  of  hamamelis  (3j  to  sviij)  is  one  of  the  best 
astringents,  and  may  be  used  in  the  relaxed  conditions  of  the 
mucous  membranes  common  in  summer  diarrheas.  Silver 
nitrate  (gr.  1  to  Oj)  may  be  used  in  ulcerative  colitis. 
Enemata  of  normal  salt  solution  are  also  used  to  relieve 
thirst  and  supply  fluid  in  cases  of  great  weakness,  as  in 
marasmus,  in  continuous  vomiting,  after  hemorrhage,  and 
plain  water  enemata  may  be  used  in  nephritis. 


THERAPEUTICS  FOR  INFANTS  AND   CHILDREN.    503 

Hot-air  Bath. — This  is  used  to  promote  sweating  in 
threatened  uremia,  etc.  The  bedclothes  are  raised  from  the 
child  by  means  of  a  wire  frame  (one  can  be  improvised  by 
using  barrel-hoops)  and  hot  air  introduced  through  an  elbow 
of  stovepipe.  A  Bunsen  burner  or  an  alcohol  lamp  is  used  to 
furnish  the  heat.  The  bath  is  continued  for  from  ten  minutes 
to  half  an  hour  or  even  longer. 

Hot  Pack.  — This  is  often  an  efficient  way  of  causing 
sweating.  A  rubber  sheet  is  placed  on  the  bed  aud  an  old 
blanket  is  laid  on  this.  The  child  is  wrapped  in  a  large 
Turkish  towel  or  an  old  blanket  which  has  been  dipped  in 
hot  water.  The  blanket  is  folded  over  the  child,  and  he 
is  allowed  to  remain  from  ten  to  twenty  minutes. 

Hot  Bath. — This  is  often  used  in  place  of  the  above,  the 
child  being  .wrapped  in  blankets  inimediatelv  afterwards. 

Salt  Bath. — Use  a  tablespoonful  of  salt  to  a  gallon  of 
water.  This  may  be  used  hot  or  cold,  and  may  follow  the 
ordinary  bath  if  desired.  The  child  is  kept  in  from  five  to 
ten  minutes,  with  friction.  It  is  used  as  a  tonic  in  poorly 
nourished  children. 

Soda  Bath. — A  heaping  teaspoonful  of  bicarbonate  of 
soda  is  used  to  each  quart  of  warm  water.  The  child  should 
remain  in  the  bath  five  minutes,  with  little  or  no  friction. 
This  is  useful  in  diseases  where  there  is  itching,  as  in  urti- 
caria and  prickly  heat. 

Bran  Bath. — A  quart  of  bran  is  placed  in  a  cheese- 
cloth bag,  then  immersed  in  the  bath  and  squeezed  about 
until  the  water  becomes  milky  white.  It  is  used  in  bathing 
children  with  irritating  skin  lesions  and  in  eczemas. 

Starch  Bath. — Two  heaping  tablespoonfuls  of  starch 
are  placed  in  the  bath.  It  is  used  for  exactly  the  same  con- 
ditions as  the  bran  bath. 

CotmterirritantS Only   mild   counterirritants   should 

be   used  in  infants    and    children.      Blisters    and  wet   cups 
should  not  be  used,  and  dry  cups  but  rarely. 

Camphorated  Oil. — This  is  a  mild  and  efficient  liniment 
much  used  in  bronchitis  as  an  application  to  the  chest- 
Mustard  Plaster. — For  children  this  should  be  made  weak  ; 


504  DISEASES  OF  INFANTS  AND  CHILDREN. 

1  part  of  mustard  to  from  1  to  6  parts  of  wheat  flour. 
This  is  made  into  a  smooth  paste  and  spread  between  two 
pieces  of  cloth  or  paper.  It  should  be  left  on  until  the  skin 
becomes  reddened,  and  the  skin  should  be  looked  at  every 
two  or  three  minutes  to  see  when  this  occurs.  The  skin 
should  be  wiped  dry.  The  application  may  be  repeated 
every  few  hours  if  desired.  If  the  plaster  is  left  on  too 
long,  the  skin  will  be  blistered  and  further  application  will 
be  impossible. 

Mustard  Pack. — This  is  sometimes  resorted  to  in  cases  of 
convulsions  and  in  other  conditions  where  it  is  desirable  to 
bring  the  blood  to  the  surface.  Four  tablespoonfuls  of 
mustard  flour  are  moistened  thoroughly  and  stirred  into  about 

2  gallons  of  hot  water.  A  large  towel  is  saturated  with  this 
and  the  body  wrapped  in  it  and  then  in  an  old  blanket.  As 
soon  as  the  skin  becomes  reddened  the  mustard  application  is 
removed  and  the  skin  thoroughly  dried. 

Mustard  Bath. — This  is  more  efficient  than  the  above,  but 
for  larger  children  is  often  not  as  conveniently  given.  Four 
tablespoonfuls  of  mustard  flour  are  stirred  up  with  a  little 
water  in  a  cup  and  the  whole  stirred  into  a  foot-tub  (about 
5  gallons)  of  water.  This  should  be  between  101°  and 
105°  F.  The  child  is  left  in  the  bath  from  two  to  ten 
minutes,  and  it  may  be  repeated  if  necessary. 

Turpentine  Stupes. — These  are  frequently  used  over  the 
abdomen  or  chest.  From  1  teaspoonful  to  1  tablespoonful 
of  turpentine  is  added  to  1  quart  of  boiling  water.  A  towel 
is  dipped  in  this,  wrung  out,  and  applied  as  hot  as  the  hand 
can  bear  (do  not  have  it  too  hot) ;  cover  this  with  several 
layers  of  woolen  cloth.  Allow  it  to  remain  until  the  skin  is 
thoroughly  reddened. 

Spice  Bag. — The  old-fashioned  spice  bag,  made  by  sewing 
up  in  a  bag  1  or  2  teaspoonfuls  of  each  of  the  powdered 
spices,  is  a  convenient  application  in  colic  and  the  milder 
pains  of  childhood.  It  is  placed  in  hot  water,  thoroughly 
squeezed  out,  and  placed  upon  the  painful  spot.  It  is  left  on 
until  the  skin  is  reddened. 

I/iniments. — Stokes's,  chloroform,  and  other  stimulating 


THERAPEUTICS  FOE  INFANTS  AUD  CHILDREN.    505 

liniments  are  often  used  ;  eare  should  be  taken  not  to  blister 
the  delicate  skin  of  the  child  by  too  strong  or  too  frequent 
applications. 

Inhalations. — Various  drugs  are  used  specially  in  the 
treatment  of  diseases  of  the  larynx  and  bronchi.  The  drugs 
to  be  vaporized  are  usually  added  to  water  and  boiled  either 
in  a  fruit  kettle  or  in  a  small  teapot.  Plain  lime-water  is 
often  used  in  bronchitis,  and  creosote,  eucalyptol,  compound 
tincture  of  benzoin,  in  proportion  of  a  dram  to  a  pint,  are 
also  of  service.  A  few  grains  of  menthol  may  be  added  to 
the  last  named  if  desired. 

Nasal  Sprays  and  Washes. — For  cleansing  the  nose 
normal  salt  solution  (^  of  1  per  cent.),  Seller's  solution,  or 
Dobell's  solution  are  the  most  frequently  employed.  The 
best  method  is  to  use  a  fountain  syringe,  having  the  bag  one 
foot  above  the  nose.  The  patient  may  be  lying  down,  in 
which  case  the  nozzle  is  placed  in  the  nostril  which  is  upper- 
most, and  the  head  may  be  turned  to  the  other  side  for  the 
other  nostril,  or  the  child  may  be  held  in  the  upright  posi- 
tion, the  head  somewhat  forward.  The  child  should  breathe 
through  the  mouth  while  the  nose  is  being  sprayed.  In 
young  infants  and  children,  where  it  is  necessary  to  cleanse 
the  throat,  the  fountain  syringe  may  also  be  used  to  ad- 
vantage, the  child  holding  its  head  face  downward  over  the 
edge  of  the  bed.  Oil  sprays  used  in  an  atomizer  or,  in  case 
of  young  infants,  dropped  in  the  nose  by  a  medicine-dropper 
are  of  great  service  (see  Coryza). 

Subcutaneous  Injection  of  Saline  Solution. — 
This  is  of  great  service  where  the  fluid  content  of  the  body 
has  been  rapidly  reduced,  as  in  some  forms  of  diarrhea  and 
vomiting.  From  1  to  5  ounces  of  a  0.9  per  cent,  solution 
(a  teaspoonful  to  a  pint,  roughly  speaking)  of  sodium  chlorid 
in  sterile  water  may  be  given  at  a  time.  The  injection  is 
given  with  a  funnel,  a  piece  of  rubber  tubing,  which  should 
be  interrupted  by  a  piece  of  glass  tubing,  and  an  aspirating 
needle.  Strict  aseptic  precautions  should  be  used.  The  loose 
tissue  about  the  abdomen  is  ordinarily  the  best  place  to  give 
the  injection,  and  the  wound  should  be  sealed  with  collodion. 


506  DISEASES  OF  INFANTS  AND  CHILDREN. 

Vaccine  Therapy. — This  is  still  in  the  experimental 
stage,  but  certain  vaccines  are  of  recognized  value  either  in 
the  prevention  of  disease  or  in  its  treatment.  Stock  vaccines 
are  prepared  from  laboratory  cultures  of  the  organisms  with- 
out reference  to  their  source.  Autogenous  vaccines  are  pre- 
pared from  the  organism  derived  from  the  patient  to  be  treated. 
As  a  general  rule  the  autogenous  vaccines  are  to  be  preferred, 
but  in  many  cases  stock  vaccines  are  nearly  or  just  as  effica- 
cious and  much  less  expensive.  The  dose  varies  with  the 
different  organisms.  The  dose  is  generally  repeated  between 
the  sixth  and  tenth  day.  If  reactions  follow  the  doses  must 
be  smaller  and  the  longer  intervals  used. 

Typhoid. — Stock  vaccines  may  be  used  to  produce  an  im- 
munity, three  doses  being  given  at  intervals  of  ten  days. 
From  100,000,000  to  500,000,000  bacilli  may  be  used  at  a 
dose.  Injections  are  best  given  about  five  o'clock  in  the 
afternoon,  so  that  if  any  reaction  occurs  it  will  be  during 
sleep.     Occasionally  fever  for  twenty-four  hours  is  noted. 

Gonococcus. — This  is  sometimes  used  in  chronic  cases  of 
vulvovaginitis  which  resist  other  forms  of  treatment.  Five 
million  may  be  given  for  the  first  dose,  and  this  may  be  in- 
creased gradually  up  to  50,000,000. 

Streptococcus. — In  streptococcus  infections,  apart  from  scar- 
let fever  and  in  erysipelas,  these  may  be  tried.  The  autog- 
enous vaccine  is  to  be  preferred — the  dose  may  vary  from 
2,000,000  for  babies  under  one  year  of  age  to  two  or  three 
times  that  amount  between  one  and  two  years  and  from 
10,000,000  to  30,000;000  for  older  children. 

Staphylococcus. — The  best  results  are  obtained  in  treatment 
in  furunculosis,  acne,  styes,  otitis  media,  osteomyelitis,  em- 
pyema, and  infection  of  the  various  sinuses.  Autogenous 
vaccine  is  to  be  preferred,  but  stock  vaccines  in  many  cases 
are  efficient.  The  variety  of  staphylococcus  should  be  de- 
termined or  mixed  vaccines  may  be  used  if  this  is  imprac- 
ticable. The  dose  may  vary  between  50,000,000  and 
100,000,000,  sometimes  more  may  be  given. 

Meningococcus. — In  widespread  epidemics  of  cerebrospinal 
fever  three  doses  have  been  suggested  to  produce  immunity. 


THERAPEUTICS  FOR  INFANTS  AND  CHILDREN.   507 

Five  million  has  been  suggested  as  the  first  dose  and 
1,000,000,000  for  the  second  and  2,000,000,000  for  the 
third.    The  doses  may  be  given  one  week  apart. 

Bacillus  Coli  Communis. — Cystitis  and  pyelocystitis,  resist- 
ing other  methods  of  treatment,  injections  from  10,000,000 
to  50,000,000  may  be  tried. 

Tuberculin. — Koch's  old  tuberculin  may  be  used  in  chronic 
localized  lesions,  beginning  with  minute  doses  of  z^  milli- 
gram, and  this  may  be  very  gradually  increased  to  T oV  o  or 

i  or  more.  Injections  should  be  made  not  closer  than 
ten*  days  as  a  rule.  The  temperature  should  be  watched,  and 
if  there  is  a  rise  the  dose  should  be  diminished  in  size.^  If 
too  much  is  used,  latent  foci  may  be  stimulated  into  activity. 


508  DISEASES  OF  INFANTS  AND   CHILDREN. 

THE  MEDICAL  INSPECTION  OF  SCHOOL 
CHILDREN. 

The  following  short  notes  are  inserted  in  this  book  for  the 
guidance  of  those  who  may  have  to  examine  school  children, 
or  who  may  be  called  upon  to  instruct  teachers  in  such  exam- 
ination. 

SCHOOL  HYGIENE.1 
Where  it  is  possible  a  record  of  the  physical  condition  for 
all  students  should  be  kept,  showing  the  principal  measure- 
ments and  the  weight,  so  that  the  development  of  the  child 
may  be  followed.  Where  it  is  possible,  notes  should  be 
made  concerning  the  food  that  the  child  receives  and  the 
kind  of  a  home  it  lives  in.  School  physicians  should  have 
the  general  supervision  of  the  hygiene  of  the  school,  and 
should  give  especial  care  to  the  lighting,  heating,  ventilation, 
drinking-water,  closets  or  outhouses,  outdoor  and  indoor  exer- 
cise for  the  children,  and  the  adjustment  of  the  seats  for  the 
pupils.  Where  it  is  possible,  they  should  urge  school  gardens. 
Care  should  be  taken  to  guard  the  pupils  against  overpressure 
and  fatigue,  and  an  effort  should  be  made  to  regulate  the 
length  of  the  school  hours  to  the  capacity  of  the  children.  It 
is  also  advisable  to  investigate  the  mental  condition  of  the 
pupil. 

THE   EYES. 

Simple  tests  should  be  taught  the  teacher  and  a  vision  chart 
supplied.  The  chart  should  not  be  exposed  except  when  the 
tests  are  being  made,  as  the  pupil  will  otherwise  become 
familiar  with  the  letters,  and  be  able  to  tell  them  from  mem- 
ory without  actually  seeing  them.  Each  pupil  should  be 
examined  separately,  and  the  examination  of  each  one  should 
be  made  privately,  and  if  the  child  is  already  wearing  glasses 
the  test  should  be  made  with  the  glasses  properly  adjusted. 
Each  eye  should  be  examined  separately,  the  other  eye  being 

1  T.  F.  Harrington,  "  Child,  the,  and  the  Public  School  Curriculum," 
Boston  Medical  and  Surgical  Journal,  September  6,  1906,  p.  247. 


MEDICAL  INSPECTION  OF  SCHOOL  CHILDREN.     509 

covered  with  a  card,  and  care  should  be  used  not  to  press  upon 
the  eye,  as,  if  pressure  is  exerted,  a  correct  test  cannot  be  made. 
The  chart  should  hang  in  a  good  light,  should  not  be  covered 
with  glass,  and  should  be  so  hung  that  the  pupil  may  be 
twenty  feet  from  it.  The  line  marked  twenty  on  the  chart 
should  be  read  by  a  normal  eye  at  the  distance  of  twenty  feet 
(Snellen's  Test  Types).  The  pupil  should  read  from  the  top 
of  the  card  downward  with  each  eye  as  far  as  he  can,  and  a 
record  be  made  of  the  result.  The  eyes  should  be  tested  each 
year  at  the  beginning  of  the  fall  term,  but  the  test  need  not 
be  made  of  the  children  in  the  first  grade  who  do  not  know 
how  to  read. 

If  a  child  cannot  read  the  "  twenty  "  line  with  either  or 
both  eyes,  the  parents  should  be  notified  of  the  fact,  and 
requested  to  have  the  eyes  examined  by  a  physician  who 
makes  a  specialty  of  the  eye.  It  should  be  remembered  that 
the  child  may  see  the  test  types  correctly,  and  yet  the  vision 
may  be  defective.  The  parents  should  be  requested  to  have 
the  child  examined  if  it  complains  frequently  of  headache 
during  school  hours,  if  the  eye  deviates  from  the  normal 
position  even  only  now  and  then,  if  the  book  is  held  nearer 
than  twelve  or  fourteen  inches  when  reading,  if  the  face 
twitches,  if  the  child  habitually  scowls  when  reading,  and  if 
the  child  does  not  make  progress  in  studies  requiring  the  use 
of  the  eyes,  but  is  bright  in  other  ways.  If  the  eyes  are  habitu- 
ally red  or  inflamed  the  attention  of  the  parents  should  be 
called  to  this  fact. 

THE  EARS. 

Each  child  should  be  tested  separately  and  alone  as  regards 
its  hearing.  The  teacher  may  make  this  test,  or  it  may  be 
made  by  the  school  physician.  The  ordinary  speaking  voice 
should  be  heard  twenty  feet  in  a  quiet  room.  The  test  should 
be  made  by  having  the  child  close  the  eyes  and  cover  the  ear 
which  is  not  being  tested  with  one  hand.  If  the  hearing  is 
not  equal  to  this  test  in  either  or  both  ears,  the  parents  should 
be  requested  to  have  the  ears  examined  by  a  competent  phy- 
sician.    A  request  for  such  an  examination  should  also  be 


510  DISEASES  OF  INFANTS  AND  CHILDREN. 

made  if  the  child  has  a  discharge  or  foul  odor  coming  from 
either  ear  or  if  the  child  complains  of  earache.  If  the  child 
is  inattentive  in  classes  which  involve  the  hearing  a  test 
should  be  made. 

THE   NOSE   AND   THROAT* 

If  there  is  a  discharge  from  one  nostril  a  foreign  body  in 
the  nose  should  be  suspected  and  an  examination  made.  If 
there  is  a  chronic  discharge  from  the  nostrils  the  nose  should 
also  be  examined.  If  the  discharge  is  not  chronic,  and  is 
purulent  in  character,  diphtheria  may  be  suspected  and  a  cul- 
ture made.  If  there  is  an  eczema  about  the  nostrils  the  head 
should  be  examined  for  lice.  If  the  child  has  repeated  nose- 
bleed, the  nose  should  be  examined,  or  the  parents  requested 
to  have  it  examined  by  a  physician. 

Adenoids  should  be  suspected,  and  the  parents  requested 
to  have  the  child  examined  by  the  family  physician  or  a  sur- 
geon, if  there  are  recurrent  attacks  of  earache  or  difficulty  in 
hearing,  frequent  colds  in  the  head,  chronic  discharge  from 
the  nostrils,  and  mouth  breathing. 

If  the  tonsils  are  very  large,  or  if  the  child  has  repeated 
attacks  of  tonsillitis,  or  if  there  are  large  cervical  glands,  a 
request  may  be  made  for  an  examination  by  the  family  phy- 
sician with  reference  to  the  removal  of  the  tonsils.  It  should 
be  remembered  that  when  the  mouth  is  wide  open  and  the 
tongue  depressed  in  an  examination  of  the  throat  that  the 
tonsils  may  seem  to  be  very  large,  when  as  a  matter  of  fact 
they  are  normal  or  nearly  so.  On  the  other  hand,  it  should 
be  borne  in  mind  that  deafness  and  earache  may  be  caused 
by  the  pressure  of  a  large  tonsil.  It  should  be  noted  in  cases 
of  recurrent  tonsillitis  whether  or  not  the  tonsil  is  bound  down 
to  the  pillars  of  the  fauces  by  adhesions.  These  adhesions 
may  be  the  cause  of  trouble  when  the  tonsil  is  not  very  large. 

In  all  acute  illnesses  the  throat  should  be  examined  for 
tonsillitis,  for  the  exanthems  of  scarlet  fever  and  of  measles,  and 
for  diphtheria.  If  diphtheria  is  suspected  a  culture  should  be 
taken. 


MEDICAL  INSPECTION  OF  SCHOOL   CHILDREN.     511 

THE    TEETH. 

The  teeth  of  most  school  children  are  badly  neglected.  The 
teeth  should  always  be  inspected  in  a  routine  examination, 
and  if  they  are  carious  the  parents  should  be  requested  to 
have  them  attended  to.  The  first  molars  of  the  permanent 
teeth  are  especially  liable  to  be  lost  by  decay,  because  they  are 
mistaken  for  the  milk  teeth.  They  are  cut  about  the  sixth 
year,  and  appear  just  back  of  the  temporary  teeth.  Diseased 
teeth  may  cause  toothache,  mouth -breathing,  neuralgia,  pain 
in  the  ear,  enlarged  glands  in  the  neck,  swelling  of  the  face, 
difficulty  in  chewing,  and  consequently  indigestion  ;  there  is 
also  indigestion  from  the  poisons  from  the  pus  and  germs 
from  diseased  teeth.  Carious  teeth  may  be  the  site  of  absorp- 
tion of  bacterial  poisons,  which  may  cause  very  serious  con- 
stitutional trouble  and  lowering  of  the  vitality.  Very  irreg- 
ular teeth  should  be  straightened  by  a  competent  dentist. 
The  general  public  is  not  educated  in  the  possibilities  of  the 
correction  of  oral  deformities. 

MENTALLY    DEFECTIVE    CHILDREN.* 
These  form  a  rather  large  and  a  very  important  class,  and 
provision    should    be    made    for    their   separate   instruction. 
Many  a  defective  child  could  be  educated  and  made  a  self- 
supporting  citizen  if  it  could  be  properly  cared  for. 

Great  care  should  be  taken  to  distinguish  between  tempo- 
rary backwardness  and  the  mentally  defective  children.  A 
child  may  be  temporarily  backward  from  various  causes, 
many  of  which  are  removable.  The  history  of  the  child's 
mental  and  physical  development  before  entering  school  is  of 
great  value,  especially  information  concerning  the  age  at  which 
it  began  to  walk,  talk,  etc.,  as  the  defective  child  usually  is 
very  much  behind  the  average  child. 

There  are  a  great  many  causes  which  may  make  a  child 
lag  behind  the  others  at  school.  Defective  sis;ht  and  hear- 
ing,  adenoids,  any  illness  causing  physical  depression,  anemia, 

1  Love,  "Cerebral  Physiology  and  the  Education  of  Abnormal  Chil- 
dren," Glasgow  Medical  Journal,  February,  1909;  pp.  90  and  242. 


512  DISEASES  OF  INFANTS  AND  CHILDREN. 

too  little  sleep,  too  much  to  do  outside  the  school,  troubles  at 
home,  lack  of  care,  and  too  little  food  may  all  make  the  child 
dull  or  appear  so.  Diseases  of  the  nervous  system,  as  well 
as  other  diseases,  should  always  be  taken  into  account.  A 
child's  previous  training  and  education  should  also  be  consid- 
ered, and  due  allowance  made  for  its  surroundings. 

Mentally  defective  children  are  usually  incapable  of  atten- 
tion for  any  great  length  of  time.  The  attention  is  easily 
diverted,  and  the  child  is  easily  fatigued  mentally.  They  do 
not  learn  easily,  and  have  difficulty  in  exercising  the  atten- 
tion, reasoning  power,  judgment,  and  will-power.  Some  of 
them  memorize  easily,  but  cannot  apply  what  they  know.  It 
is  common  for  the  child  to  have  attended  school  for  several 
years  without  learning  to  read  or  cipher.  They  usually 
associate  with  children  younger  than  themselves,  and  are  often 
precocious  sexually.  They  are  often  stubborn,  excitable,  and 
what  is  commonly  called  incorrigible.  They  are  frequently 
very  untidy  in  their  habits.  They  usually  exhibit  some  of 
the  stigmata  of  degeneration  (see  same).  Usually  the  expres- 
sion denotes  a  low  grade  of  intellect,  the  body  is  ungraceful 
and  unattractive,  and  the  movements  are  awkward.  Some 
defective  children  are  but  little  below  the  average  intellect, 
but  are  morally  defective.  They  lie,  steal,  are  frequently 
destructive,  and  often  commit  other  crimes.  Some  defective 
children  delight  in  cruel  acts. 

NERVOUS   DISEASES. 

The  teacher  should  be  instructed  to  refer  for  examination 
all  cases  suggesting  diseases  of  the  nervous  system.  The  fol- 
lowing are  points  for  the  teacher  to  know  : 

Chorea. — A  child  who  was  previously  quiet  becomes 
very  nervous  and  is  not  able  to  sit  or  stand  still.  There  are 
awkward  twitching  movements  of  the  muscles,  and  the  child 
often  drops  things  which  it  is  holding.  Writing  and  draw- 
ing are  interfered  with.  The  child  is  irritable,  loses  its  tem- 
per easily,  and  is  unable  to  keep  its  attention  fixed. 

Habit  Spasm. — This  should  not  be  confused  with  the 
above.     The  habit  spasm  is  characterized  by  the  same  move- 


MEDICAL  INSPECTION  OF  SCHOOL   CHILDREN.     513 

merit,  usually  a  grimace,  a  twitching  of  the  muscles  about  the 
eye,  or  a  movement  of  some  part  of  the  body.  A  child  with 
a  habit  spasm  need  not  leave  school. 

Epilepsy. — The  two  forms,  major  and  minor,  should  be 
explained.  In  minor  epilepsy  there  is  a  temporary  loss  of 
consciousness,  the  child  stares,  stops  what  he  is  doing,  the 
lips  may  become  blue,  and  there  may  be  some  unusual  move- 
ment. The  child  does  not  remember  anything  about  this. 
Any  senseless  movement  which  the  child  makes  from  time 
to  time,  and  which  it  does  not  remember,  should  lead  to  an 
examination  for  minor  epilepsy.  The  major  attack,  with  its 
fall,  convulsion,  jerking  movements,  cyanosis,  loss  of  con- 
sciousness, is  usually  easily  diagnosed.  The  child  may  injure 
itself  in  the  fall,  and  the  tongue  may  be  bitten  and  the  urine 
and  feces  may  be  passed. 

Hysteria. — The  convulsion  of  hysteria  should  not  be  con- 
fused with  epilepsy.  The  hysterical  convulsion  is  a  noisy 
one,  the  child  talks,  sings,  cries,  makes  all  sorts  of  move- 
ments, may  answer  questions,  and  rarely  hurts  itself  in  the 
fall,  and  does  not  bite  the  tongue,  and  rarely  passes  either 
urine  or  feces. 

Nervousness. — Many  children  are  very  nervous,  having 
often  a  neurotic  familv  taint,  or  sometimes  have  become  so 
through  too  much  work,  too  little  exercise,  worry,  and  a  lack 
of  sleep,  food,  and  care.  The  teacher  should  be  instructed 
to  try  to  make  friends  with  such  children  and  to  determine 
the  cause  of  the  nervousness,  and  if  possible  to  have  it  removed. 
If  the  cause  is  not  removable,  such  children  should  be  care- 
fully looked  after  to  j^revent  further  development  of  the 
trouble. 

Paralysis. — All  children  with  paralysis  should  be  referred 
to  the  school  physician  for  examination. 

PHYSICAL   DEFECTS. 

All  children  with  physical  defects  should  be  examined  by 
the  school  physician.  Children  with  one  shoulder  higher 
than  the  other  and  those  with  stooped  shoulders  should  be 
looked  for  especially,  as  in  manv  instances  proper  exercise 


514  DISEASES  OF  INFANTS  AND  CHILDREN. 

and  proper  desks  will  correct  what  might  otherwise  become 
an  ugly  deformity.  Sometimes  these  deformities  are  signs  of 
serious  spinal  disease.  Lameness  may  be  due  to  improper 
shoes  or  to  disease  of  the  bone,  joints,  or  nerves. 

SKIN    DISEASES. 

The  teacher  should  be  on  the  lookout  for  diseases  of  the 
skin,  especially  the  contagious  ones.  Impetigo  contagiosa, 
scabies,  favus,  ringworm-,  head-  and  body-lice  are  the  most  fre- 
quent ones,  and  the  ones  which  should  be  excluded  from 
school  (see  Skin  Diseases).    , 

OTHER   SYMPTOMS* 

The  teacher  should  be  instructed  in  regard  to  the  follow- 
ing symptoms,  and  children  with  any  of  them  should  be 
referred  to  the  physician  for  examination. 

Skin  Eruptions. — These  may  be  the  eruptions  of  the 
infectious  diseases — scarlet  fever,  measles,  German  measles, 
or  chicken-pox,  or  some  infectious  skin  disease — and  should 
always  be  investigated  promptly. 

Irritating  Discharge  from  the  Nose. — This  may  be 
an  indication  of  diphtheria. 

Running  Nose  and  Eyes,  especially  with  Drow- 
siness and  Cough. — These  symptoms  should  suggest 
measles. 

Flushing  of  the  Face. — This  usually  indicates  that 
the  child  has  fever,  and  he  should  be  examined. 

Cough.— A  spasmodic  cough  may  be  whooping-cough  ;  a 
croupy  cough  may  mean  diphtheria,  a  chronic  cough  may 
mean  tuberculosis,  and  a  cough  which  is  painful  may  mean 
pneumonia  or  pleurisy.  Usually  a  cough  merely  means  a 
"  cold  "  ;  that  is,  a  simple  bronchitis. 

Vomiting. — This  may  be  the  beginning  of  an  acute 
infectious  disease,  especially  scarlet  fever.  Usually  it  means 
some  disturbance  of  digestion,  often  caused  either  by  too  much 
or  by  improper  food. 

Swelling  of  the  Face,  Hands,  or  I^egs. — This  may 
mean  serious  disease  of  the  kidneys,  and  should  always  be 


MEDICAL  INSPECTION  OF  SCHOOL   CHILDREN.     515 

promptly  investigated.  It  may  also  indicate  either  heart  or 
kidney  disease. 

Shortness  of  Breath. — This  may  mean  either  disease 
of  the  heart  or  lungs. 

Swellings  Ahout  the  Neck. — These  may  be  enlarged 
lymph-nodes,  the  cause  of  which  should  always  be  sought  for 
by  the  physician.      Mumps  may  be  the  cause. 

Paleness. — This  means  anemia.  If  associated  with  emaci- 
ation it  indicates  some  disease  or  disturbance  of  nutrition  ;  if 
in  a  girl  who  is  well  nourished,  short  of  breath,  and  who  has 
a  sort  of  greenish  pallor,  it  may  be  chlorosis ;  if  associated 
with  swelling  or  purfiness  of  the  face  it  may  be  an  indication 
of  heart  disease  or  kidney  disease. 

Emaciation. — This  may  indicate  malnutrition  or  some 
serious  disease. 

INFECTIOUS    DISEASES. 

The  teacher  and  the  school  physician  should  exercise  great 
care  in  watching  for  infectious  diseases.  The  teacher  should 
be  instructed  in  the  detection  of  these  diseases.  The  follow- 
ing points  will  be  found  useful : 

Scarlet  Fever. — A  sudden  onset  with  vomiting,  head- 
ache, sore  throat,  and  high  fever  should  always  lead  to  the 
isolation  of  the  child.  A  child  coming  to  school  with  the 
skin  peeling  off,  especially  after  an  acute  illness,  should  always 
be  regarded  as  a  source  of  danger  until  an  examination  has 
been  made  by  the  school  physician.  The  same  is  true  of  a 
running  ear. 

Measles. — A  combination  of  sore  eyes  and  a  slight  dread 
of  light,  coryza,  sore  throat,  and  a  cough  should  suggest  mea- 
sles.    The  mouth  should  be  examined  for  Koplik  spots. 

Chicken-pox. — Small  vesicles  and  a  few  pustules  should 
suggest  chicken-pox,  and  the  black  scabs  of  the  later  stage 
may  be  regarded  with  equal  suspicion. 

Diphtheria. — A  mild,  unrecognized  case  of  diphtheria 
may  be  responsible  for  an  epidemic  in  a  school.  It  is  impor- 
tant that  all  cases  of  sore  throat,  running  of  the  nose,  especi- 
ally if  the  discharge  is  purulent,  or  if  the  upper  lip  is  inflamed, 


516  DISEASES  OF  INFANTS  AND   CHILDREN. 

and  of  hoarseness  should  be  investigated  promptly.  Any  mem- 
brane in  the  nose  or  throat  should  lead  to  prompt  isolation. 

Whooping-cough. — A  persistent  spasmodic  cough, 
cough  with  vomiting,  and  cough  with  ulceration  of  the  fre- 
niira  of  the  tongue  should  all  be  looked  on  with  suspicion, 
and  the  case  reported. 

Mumps. — Any  swelling  at  the  angle  of  the  jaw  and  just 
under  the  ear  should  be  reported. 

Danger  from  Infectious  Diseases  after  Expos- 
ure.— The  question  of  how  long  a  time  must  elapse  before 
there  is  no  danger  of  a  child  developing  an  infectious  disease 
after  exposure  is  frequently  asked.  Also  how  infectious  are 
the  various  communicable  diseases. 

Scarlet  Fever. — Little  danger  after  one  week  has  elapsed, 
but  ten  or  twelve  days  is  a  safer  time  to  state.  About  half 
the  children  exposed  take  the  disease. 

Measles. — Little  danger  after  sixteen  days  and  practically 
none  after  twenty-two  days.  Almost  every  child  exposed 
takes  the  disease. 

German  Measles. — Little  danger  after  three  weeks  and  none 
after  six.  The  disease  is  but  feebly  contagious  ;  from  one- 
third  to  one-half  the  children  exposed  take  the  disease. 

Varicella. — Little  danger  after  seventeen  days  and  practi- 
cally none  after  three  weeks.  Almost  all  children  exposed 
take  the  disease. 

Small-pox. — Little  danger  after  sixteen  days.  Almost 
everyone  exposed  takes  the  disease  unless  protected  by  suf- 
ficient vaccination. 

Diphtheria. — Little  danger  after  four  days  and  practically 
none  after  one  week.     The  susceptibility  is  very  general. 

Whooping-cough. — There  is  but  little  danger  after  sixteen 
days  and  perhaps  none  after  three  weeks.  The  susceptibility 
is  general. 

Mumps. — Little  danger  after  four  weeks.  Cases  are  on 
record  thirty-five  days  after  exposure.  About  one-third  of 
the  children  exposed  to  mumps  contract  the  disease.  In 
some  epidemics  the  proportion  is  very  much  greater. 

Typhoid  Fever. — Little  anxiety  need  be  felt  after  three 
weeks  have  elapsed.     The  susceptibility  is  rather  general. 


MEDICAL  INSPECTION  OF  SCHOOL  CHILDREN.     517 

The  Return  of  Children  to  School  after  Infec- 
tious Diseases. — This  is  a  question  which  comes  up  very 
frequently. 

Scarlet  Fever. — Desquamation  should  be  completed  over 
the  entire  body,  the  discharge  from  ears  and  nose  should  have 
entirely  ceased,  there  should  be  no  albuminuria,  and  there 
should  be  no  discharging  abscesses  or  wounds  which  have 
resulted  from  complications.  The  inflammation  in  the  throat 
should  be  entirely  well. 

Measles. — The  desquamation  should  be  entirely  completed, 
and  the  child  should  be  well  from  the  bronchitis  which  always 
accompanies  measles. 

German  Measles. — The  desquamation  should  be  entirely 
completed. 

Varicella. — Every  scab  should  have  separated  and  the  child 
be  entirely  clean.  Care  should  be  taken  to  examine  the  scalp, 
as  the  crusts  persist  there  longer  than  elsewhere. 

Small-pox. — A  week  after  the  complete  separation  of  every 
scab  and  after  the  skin  has  become  entirely  clean.  All 
abscesses  and  the  like  should  be  entirely  healed. 

Diphtheria. — The  child  should  be  entirely  well.  There 
should  be  no  discharges  from  the  nose,  no  albuminuria,  and 
the  cultures  from  the  nose  and  throat  should  be  negative. 
At  least  two  cultures  should  be  taken  at  intervals  of  forty- 
eight  hours.  The  so-called  "  latent "  cases  are  a  great  danger 
in  spreading  the  disease  (see  Latent  Diphtheria,  Myer  Solis- 
Cohen,  Journal  of  the  American  Medical  Association,  Julv  6, 
1907,  page  30). 

Whooping-cough. — The  spasmodic  cough  should  have  been 
absent  at  least  two  weeks,  and  a  better  rule  is  to  wait  until 
the  cough  has  disappeared  entirely. 

Mumps. — At  least  one  week  should  elapse  after  the  swell- 
ing and  tenderness  have  disappeared  from  the  glands.  In 
exceptional  cases  the  patient  is  a  source  of  danger  much  longer, 
but  the  rule  given  is  reasonably  safe. 


518  DISEASES  OF  INFANTS  AND  CHILDREN. 


THE  MEASURING  OF  THE  DEVELOPMENT  OF  THE  INTEL- 
LIGENCE OF  CHILDREN. 

Binet  and  Simon  have  devised  a  scale  for  measuring  the 
intelligence  of  children,  and  by  the  use  of  the  scale  it  is  easy 
to  ascertain  whether  the  child  under  examination  gives  re- 
sults equal  to  the  normal  child  of  his  age  or  whether  he  is 
advanced  or  retarded.  Feeble-minded  children  may  be  divided 
into  three  classes  :  idiots,  imbeciles,  and  morons.  The  idiot 
never  reaches  the  plain  spoken  language,  but  is  limited  to 
the  use  and  understanding  of  gesture.  The  imbecile  under- 
stands spoken  language  and  talks  himself  in  varying  degrees 
of  fluency.  The  moron,  in  addition  to  using  spoken  lan- 
guage, is  capable  of  learning  to  read  and  write.  In  Binet's 
scale  the  idiots  come  in  group  one  or  two,  the  imbeciles  cor- 
respond to  the  ages  three,  four,  five,  six,  and  seven,  and  the 
morons  to  the  ages  of  eight,  nine,  ten,  eleven,  and  twelve. 
The  feeble-minded  child  does  not  develop  beyond  this  period. 

Mentality  of  One  and  Two  Years. 

1.  Eye  follows  light. 

2.  Block  placed  in  hand  is  grasped  and  handled. 

3.  Candy  is  chosen  instead  of  block. 

4.  Paper  is  removed  from  candy  before  eating,  the  child 
having  seen  the  wrapping. 

5.  Child  executes  simple  commands  and  imitates  simple 
movements. 

Three  Years. 

6.  Shows  nose,  eyes,  and  mouth. 

7.  Repeats  two  digits,  as  2-4. 

8.  Enumerates  objects  in  a  picture. 

9.  Gives  family  name. 

10.  Repeats  a  sentence  of  six  syllables  without  error. 

Four  Years. 

11.  Names  his  sex,  as  boy  or  girl. 

12.  Names  small  objects,  as  key,  knife,  and  penny. 


MEDICAL  INSPECTION  OF  SCHOOL   CHILDREN.    519 

13.  Repeats  three  numerals,  as  5-2-8. 

14.  Can  tell  which  is  the  longer  of  two  lines  drawn  par- 
allel an  inch  apart  and  one-third  of  an  inch  difference  in 
length. 

15.  Knows  family  name.     Occasional  failure  in  this. 

Five  Years. 

16.  Tells  which  is  heavier  of  two  blocks  of  wood  of  equal 
size  and  appearance,  one  weighted. 

17.  Can  copy  a  square. 

18.  Can  repeat  an  easy  sentence  of  ten  syllables. 

19.  Can  count  four  pennies. 

20.  Can  rearrange  a  rectangular  card  that  has  been  cut 
diagonally  into  two  triangles.  Ask  the  child  to  make  a  figure 
like  the  uncut  card.     One  child  in  twelve  fails. 

21.  Knows  whether  it  is  morning  or  afternoon.  Remem- 
ber that  certain  children  will  always  answer  the  last  of  two 
alternatives.  If  it  is  morning,  put  the  question  "Is  it 
morning  or  afternoon  ?  " 

22.  Executes  three  commissions,  given  simultaneously,  as, 
Take  this  key,  put  it  on  that  chair,  then  shut  the  door.  After 
that  bring  me  the  box  that  is  on  the  chair. 

23.  Can  show  right  hand  and  left  ear.  Say  "  Show  me 
your  right  hand,"  and  when  this  is  done,  "  Show  me  your 
left  ear."  At  four,  no  child  points  to  the  left  ear.  At  five, 
half  the  children  make  a  mistake.     At  six,  all  succeed. 

24.  Distinguishes  pretty  from  distinctly  ugly  or  deformed 
faces  in  a  picture.  At  six,  all  choose  correctly.  At  five, 
about  half. 

Seven  Years. 

25.  Counts  thirteen.  They  should  be  placed  in  a  row  and 
counted  with  the  finger.  The  finger  must  touch  the  piece  at 
the  same  time  that  the  child  names  the  number,  and  no  piece 
should  be  counted  twice  and  none  omitted. 

26.  Describes  pictures.  Binet  used  three  pictures.  ^  The 
first  is  a  man  and  a  boy  drawing  a  cart  loaded  with  furniture. 
The   second,  a  woman  and  a  man  sitting  on  a  bench  in  the 


520  DISEASES  OF  INFANTS  AND  CHILDREN. 

park.  The  third,  a  man  in  prison  looking  out  of  the  window, 
a  couch,  chairs,  and  tables.  The  child  of  three  names  the 
things.     The  child  of  seven  describes  what  is  going  on. 

27.  Notes  omission  of  nose,  mouth,  or  arms  from  sketches. 

28.  Draws  diamond  shape  from  copies  so  that  it  can  be 
recognized. 

29.  Names  four  colors.  Use  red,  green,  blue,  and  yellow 
papers  in  pieces  of  about  one  to  two  inches.  Touch  the  color 
with  the  finger  and  ask,  "  What  is  this  color?"  It  should 
be  done  in  six  seconds. 

Eight  Years. 

30.  Compares  two  things  from  memory,  as  "  What  is  the 
difference  between  a  butterfly  and  a  fly  ?  "  A  glass,  paper, 
and  cloth  ?  At  least  two  out  of  three  should  be  answered 
correctly.  If  it  takes  over  two  minutes  it  is  a  failure.  At 
six,  one-third  of  the  children  do  this  test.  At  seven,  nearly 
all,  and  at  eight,  all. 

31.  Can  count  backward  from  twenty  to  one.  This  should 
be  done  in  twenty  seconds  with  not  more  than  one  mistake. 

32.  Names  the  days  of  the  week  in  order  in  ten  seconds. 

33.  Can  count  the  value  of  six  stamps,  three  ones  and 
three  twos,  in  less  than  fifteen  seconds.  Arrange  these  in 
order,  one,  one,  one,  two,  two,  two,  and  ask  how  much  are 
they  worth  or  how  much  will  it.  take  to  buy  them  ? 

34.  Repeats  five  numerals  in  order  when  pronounced  once, 
as  3-7-2-5-4.     About  25  per  cent.  fail. 

Nine  Years. 

35.  Can  give  correct  change,  play  store,  using  real  money. 
The  child  should  be  storekeeper  with  cash  consisting  of  twenty- 
five  pennies,  five  nickles,  and  two  dimes.  One  buys  some- 
thing that  costs  seven  cents.  The  child  should  return  eighteen 
cents  in  change  as  well  as  say  it.  At  seven  none  do  this, 
at  eight  one-third  succeed,  at  nine  all  do  it. 

36.  Defines  the  objects  fork,  table,  heat,  horse,  mamma  in 
other  words  than  the  statement  of  their  use. 


MEDICAL  INSPECTION  OF  SCHOOL  CHILDREN.    521 

37.  Names  the  day  of  the  week,  the  month,  the  day  of 
the  month,  and  the  year.  If  the  child  gets  within  three  days 
of  the  day  of  the  mouth  it  has  passed. 

38.  Can  name  the  months  of  the  year.  Recite  them  in 
order  within  fifteen  seconds.  One  omission  or  transposition 
is  allowed. 

39.  Arrange  in  order  and  weight  boxes  of  the  same  size 
and  appearance,  weighing  6,  9,  12,  15,  and  18  grams.  This 
can  be  done  in  two  minutes  in  two  out  of  three  trials. 

Ten  Years. 

40.  Can  name  nine  pieces  of  money,  as  cent,  nickle,  dime, 
quarter,  half  dollar,  two,  five-  and  ten-dollar  bills.  This  should 
be  done  in  forty  seconds.  The  pieces  should  be  placed  on  a 
table  in  a  row,  but  not  in  the  order  of  value,  and  should  be 
named  when  pointed  to. 

41.  Can  copy  simple  design  from  memory  after  ten  seconds' 
exposure. 

42.  Can  repeat  six  numerals,  as  8-5-4—7-2-6.  Can  tell 
what  one  should  do  in  various  emergencies.  Ask,  for  ex- 
ample, "  What  would  you  do  if  you  missed  a  train  ?  "  Correct 
answer  is,  "  Wait  for  another  train  or  take  the  next."  In- 
correct answers  :  "  I  would  try  not  to  miss  it,  run  after  it, 
buy  a  ticket."  "  What  would  you  do  if  one  of  your  play- 
mates should  hit  you  without  wanting  to  do  so  ?  "  Correct 
answer,  "Do  nothing  to  him,  excuse  him,  pardon  him,  tell 
him  to  be  more  careful  another  time."  Incorrect  answer : 
"  Tell  the  teacher  or  punish  him."  "  What  would  you  do  if 
you  broke  something  belonging  to  some  one  else  ?  "  Correct 
answer  is,  "  Pay  for  it.  Ask  to  be  excused.  Replace  it. 
Confess  it."  Incorrect  answers  to  this  are  generally  unin- 
telligible. The  test  is  considered  passed  if  two  of  the  three 
questions  are  answered  satisfactorily. 

43.  Uses  three  given  words  in  two  given  sentences,  as 
Baltimore,  money,  and  river.  One  minute  should  be  allowed. 
At  eight  none  succeed,  at  nine  one-third,  and  at  ten  one- 
half.  The  question  should  be  answered  either  in  a  single  idea 
involving  the  three  words  or  ideas  involving  conjunction  not 


522  DISEASES  OF  INFANTS  AND  CHILDREN. 

in  three  separate  sentences.  This  test  shows  the  distinction 
between  intelligence  and  judgment.  Some  children  give  a 
complete  sentence  with  three  words,  but  without  sense  to  it. 

Eleven  Years. 

44.  Detects  nonsense  in  three  out  of  five  statements  in  two 
minutes.  The  statement  should  be  made  to  the  child,  "  I  am 
going  to  give  you  some  sentences  in  which  there  is  some  non- 
sense and  you  listen  carefully  and  tell  me  what  it  is.  Binet 
uses  the  following  : 

1.  A  bicyclist  fell  and  broke  his  neck  and  died  on  the  spot. 
He  was  taken  to  the  hospital  and  they  fear  very  much  that 
he  cannot  get  over  it. 

2.  I  have  three  brothers,  John,  Jim,  and  myself. 

3.  Yesterday  the  police  found  the  body  of  a  young  girl 
cut  into  eighteen  pieces.  They  believe  that  she  killed  her- 
self. 

4.  Yesterday  there  was  a  railroad  accident,  but  it  was  not 
serious.     The  number  of  deaths  was  only  48. 

5.  Some  one  said  if,  in  a  moment  of  despair,  I  should  com- 
mit suicide  I  should  not  choose  Friday,  because  Friday  is  an 
unlucky  day  and  it  would  bring  me  ill  luck. 

6.  A  man  was  about  to  be  hanged,  and  said  this  will  teach 
me  a  lesson  how  to  behave  in  the  future. 

About  two  minutes  should  be  taken  for  this  test.  At  least 
three  of  the  questions  should  receive  satisfactory  answers. 
At  nine  the  child  rarely  answers  correctly,  at  ten  about 
one-fourth,  and  at  eleven  about  one-half. 

45.  Uses  three  words  in  a  sentence  the  same  as  under  ten 
years  of  age.     At  eleven  all  succeed. 

46.  Can  say  as  many  as  sixty  words  in  three  minutes,  as 
board,  chair,  table,  draw,  wagon. 

47.  Can  name  three  words  that  rhyme  in  one  minute.  Can 
use  a  simple  word,  as  day,  spring,  mill. 

48.  Can  arrange  eight  words  correctly.  Three  simple  sen- 
tences of  eight  words  should  be  given.  The  words  should 
be  printed. 


MEDICAL  INSPECTION  OF  SCHOOL  CHILDREN.    523 


Twelve  Years. 

49.  Can  repeat  seven  numerals  in  order  when  heard  once. 
Give  three  trials.     One  success  is  sufficient, 

50.  Can  give  abstract  definitions,  as  of  charity,  justice, 
goodness. 

51.  Can  repeat  a  sentence  of  twenty-six  syllables,  as,  The 
other  day  I  saw  on  the  street  a  pretty  young  dog.  Little 
Morris  has  got  spots  on  his  apron. 

52.  Rejects  suggestions  as  to  the  length  of  lines.  Make 
a  booklet  of  six  pages.  On  the  first  page  draw  two  hori- 
zontal lines  in  ink.  The  one  to  the  left  2  inches  long,  the 
one  on  the  right  2  |  inches.  On  the  second  page  the  one  to 
the  left  is  2J  and  on  the  right  3  inches.  On  the  third  the 
left  line  is  3^  and  the  right  3 J  inches.  On  the  three  remain- 
ing pages  all  lines  are  3J  inches  long.  When  the  child  has 
found  the  right  line  longer  three  times  in  succession,  will  he 
continue  to  make  this  judgment  even  when  he  comes  to  those 
that  are  alike  or  will  he  reject  suggestions  and  pronounce 
them  alike  ?  For  the  first  two  pages  ask  which  is  the  longest 
line.     For  the  others  say  merely,  "  And  there  ?  " 

53.  Gives  the  correct  inference  from  a  problem  of  various 
facts,  as  What  is  it?  A  man  was  walking  in  the  woods  near 
Baltimore,  and  suddenly  stopped  very  much  frightened,  and 
then  ran  to  the  police  station  to  tell  them  that  he  had  just 
seen  hanging  from  the  limb  of  a  tree  a  .  .  .  .  My  neighbor 
has  just  received  some  peculiar  visits.  There  came  one  after 
another  a  doctor,  a  lawyer,  and  a  minister.  What  is  going 
on  at  my  neighbor's?  Such  answers  as  a  dead  person  is 
hanging,  my  neighbor  is  dying,  are  correct. 

Fifteen  Years. 

54.  Writes  correctly  the  opposite  of  seventeen  out  of 
twenty  given  words.  Use  such  words  as  good,  outside,  tall, 
quick,  loud. 

55.  Can  imagine  the  hands  of  a  clock  at  any  given  hour 
transposed  and  tell  what  time  it  would  then  be. 


524  DISEASES  OF  INFANTS  AND  CHILDREN. 

56.  Can  interpret  pictures,  in  addition  to  enumerating  and 
describing  the  objects  in  them. 

Over  Fifteen  Years. 

57.  Distinguishes  between  abstract  terms  of  similar  sound 
and  meaning,  such  as  pleasure,  welfare,  event,  and  prevent. 

58.  Can  give  the  difference  between  the  president  of  a 
republic  and  a  king. 

59.  Can  imagine  and  draw  the  new  form  produced  by 
joining  transposed  pieces  of  a  diagonally  divided  rectangular 
card. 

60.  Imagines  and  draws  the  result  of  cutting  triangular 
forms  of  twice-folded  paper.  Fold  a  square  paper  twice, 
allowing  the  person  to  see  it  done,  and  then  cut  a  small  equi- 
lateral triangle  with  its  base  on  the  middle  of  the  closed  edge. 
Have  the  person  draw  the  paper  as  it  will  look  when  un- 
folded. 

61.  Can  give  the  central  thought  of  a  selection  read  to 
him.  For  this  purpose  the  following  is  used  :  "  Many 
opinions  have  been  given  on  the  value  of  life.  Some  call  it 
good  ;  others  call  it  bad.  It  would  be  more  just  to  say 
that  it  is  mediocre ;  but  on  the  one  hand,  our  happiness  is 
never  so  great  as  we  would  have  it  and,  on  the  other  hand, 
our  misfortunes  are  never  so  great  as  others  would  have 
them.  It  is  this  mediocricity  of  life  which  prevents  it  from 
being  radically  unjust." 

This  method  of  testing  the  intelligence  of  children  is  very 
valuable,  particularly  for  determining  what  should  be  done 
in  regard  to  a  child's  schooling.  The  test  is  not  as  simple 
as  it  looks,  and  accurate  results  can  only  be  obtained  after 
considerable  practice.  The  child  should  be  examined  alone, 
and  should  not  be  criticized  or  instructed  at  the  time  of  the 
examination.  The  results  of  the  examination  should  be  re- 
corded at  the  time  made.  A  child  has  the  intelligence  at  that 
age  all  the  tests  that  he  succeeds  in  passing.  After  deter- 
mining the  age  for  which  a  child  passes  all  the  tests  a  year  is 
added  to  the  intelligence  age  if  he  has  succeeded  in  passing 
five  additional  tests  belonging  to  superior  age  groups.     Two 


MEDICAL  INSPECTION  OF  SCHOOL  CHILDREN.    525 

years  are  added  if  he  has  passed  ten  such  tests,  three  years 
if  he  has  passed  fifteen,  etc.  Thus,  a  child  passed  five  tests 
for  the  seventh  year,  and  also  three  for  the  eighth  and  two  for 
the  ninth,  add  one  year  for  the  five  tests.  These  tests  are 
for  average  children.  Those  from  the  better-class  homes  will 
generally  show  a  higher  intellectual  development.  The  same 
examination  should  not  be  made  too  frequently,  and  the  child 
should  not  be  coached  in  giving  correct  answers.  It  must  be 
remembered  that  this  scale  is  one  which  must  be  used  with 
common  sense,  and  the  examination  must  be  made  in  accord- 
ance with  certain  restrictions,  and  where  it  is  to  be  used  Binet 
and  Simon's  original  work  may  be  consulted  to  great  ad- 
vantage.1 

1  UA  Method  of  Measuring  the  Development  of  the  Intelligence  of 
Young  Children,"  Binet  and  Simon,  translated  by  Clara  Harrison  Town, 
published  by  the  Courier  Co.,  Lincoln,  111.  ;  "  A  Syllabus  for  the  Clinical 
Examination  of  Children,"  by  Huey,  published  by  Warwick  and  York, 
Baltimore,  Md. ;  "  Manual  of  Mental  and  Physical  Tests,"  by  Whipple, 
published  by  Warwick  and  York,  Baltimore,  Md. ;  "The  Conservation  of 
the  Child,"  by  Arthur  Holmes,  Lippincott  Company,  Philadelphia,  Pa. 

It  should  be  remembered  that  in  early  examination  the 
child  may  not  answer  because  it  is  frightened,  or  it  may  vol- 
untarily remain  mute  and  motionless,  especially  children  of 
three  and  four.  A  too  hasty  conclusion  should  not  be  formed 
as  to  the  child's  mental  condition,  and  it  should  be  remem- 
bered that  at  best  the  estimate  is  only  approximate.  The 
child  may  show  a  retardation  in  its  development,  but  this  is 
not  to  be  taken  as  an  evidence  of  feeblemindedness,  unless 
there  is  a  retardation  of  three  years  or  of  two  years  for  the 
child  under  nine,  and  due  allowance  must  be  made  for  the 
advantages  which  a  child  may  or  may  not  have  had.  It  may 
be  remembered  that  enumeration  of  objects  normal  to  about 
three  years  of  age,  that  about  seven  the  child  begins  to  de- 
scribe objects,  while  interpretation  of  pictures  or  events  gen- 
erally is  not  noted  until  about  fifteen. 


526  DISEASES   OF  INFANTS  AND  CHILDREN. 

SAMPLE  PAMPHLET  OF  INFORMATION  FOR  DIS- 
TRIBUTION AMONG  THE  POOR  IN  SUMMER. 

9 

Nurse  the  baby,  mother's  milk  is  the  best  of  all  foods. 

Do  not  wean  the  baby  in  hot  weather. 

Remember  that  ten  bottle  babies  die  to  one  that  is  breast- 
fed. 

One-third  of  the  deaths  of  infants  and  young  children 
occur  during  the  hot  summer  months. 

Heat  kills  the  baby  chiefly  by  spoiling  the  milk  given  it. 

Nurse  the  baby  regularly,  not  often er  than  two  hours  dur- 
ing the  day  and  four  hours  at  night.  After  three  months  of 
age  do  not  nurse  oftener  than  every  three  hours.  No  night 
feedings  are  necessary  after  five  months. 

Do  not  nurse  the  baby  every  time  it  cries. 

If  you  cannot  nurse  your  baby,  consult  your  doctor  before 
giving  it  the  bottle. 

Fresh  Air. — Give  the  baby  fresh  air  day  and  night. 

Keep  the  windows  open  all  day  and  all  night. 

Keep  the  baby  out  of  doors  as  much  as  you  can. 

The  out-door  air  is  better  for  the  baby  than  that  of  the 
house. 

The  air  in  the  squares  and  parks  is  better  than  that  of  the 
streets. 

Keep  the  rooms  clean. 

Do  not  let  garbage,  slop,  or  dirty  clothes  stand  about  the 
room. 

Sleep. — Do  not  let  the  baby  sleep  in  the  same  bed  with  any 
other  person. 

Keep  the  baby  quiet,  and  let  it  sleep  as  much  as  it  will. 

Do  not  handle  the  baby  too  much  ;  let  it  alone. 

Bathing. — Bathe  the  baby  every  day. 

In  very  hot  weather  sponge  the  baby  several  times  a  day 
to  keep  it  clean  and  cool. 

Wash  the  baby  whenever  the  diapers  are  changed. 

Clothing. — The  baby  feels  the  heat  as  much  or  more  than 
you. 

In  hot  weather  take  off  most  of  the  baby's  clothing. 


INFORMATION  FOR  POOR  IX  SUMMER  527 

If  it  becomes  cold  the  clothing  can  easily  be  put  back. 

If  the  baby  has  fever,  take  some  of  the  clothing  off,  but  do 
not  put  more  on.      A  babv  with  fever  will  not  catch  cold. 

Diapers. — Wash  the  diaper  as  soon  as  it  is  soiled,  and  dry 
in  the  open  air. 

Do  not  use  a  diaper  a  second  time  before  washing  it. 

Water. — In  hot  weather  the  baby  needs  a  little  more  water 
an  1  not  so  much  food. 

Give  a  few  teaspoonfuls  of  pure,  boiled  water  several  times 
a  day. 

Summer  diarrhea  is  caused  by  spoiled  milk  or  other  food, 
bad  air,  dirt,  and  too  much  clothing,  too  much  handling,  too 
little  sleep,  too  little  water. 

If  the  baby  vomits  or  has  loose  bowels,  stop  all  food 
and  give  plain,  boiled  water  until  you  have  seen  your  doctor. 

Do  not  drus:  the  baby.  If  your  babv  is  sick  send  for  a 
doctor  or  take  it  to  a  hospital  or  dispensary. 

Do  not  ask  your  neighbor's  advice  about  your  baby,  ask 
your  doctor. 

The  Bottle-fed  Baby. — The  Bottles. — Use  a  common 
round-bottomed  bottle ;  boil  or  scald  it  each  time  before  put- 
ting the  baby's  milk  in  it. 

The  Xipples. — Use  plain  black-rubber  nipples.  Boil  them 
once  a  day.  Wash  the  nipples  before  and  after  each  feeding. 
TYnen  not  in  use,  keep  the  nipples  iu  a  covered  glass  filled 
with  water  in  which  you  have  put  a  pinch  of  baking  soda  or 
borax. 

Xever  use  a  nipple  with  a  tube  to  it. 

Tlie  Mill:. — Get  only  the  best  milk  for  the  baby.  Better 
pay  more  for  milk  and  save  doctor's  bills  and  possibly  funeral 
expenses.  It  costs  less  to  buy  a  baby  good  milk  for  a  year 
than  to  bury  it. 

The  best  milk  is  bottled  at  the  dairy  and  delivered  in 
bottles.  Milk  sold  from  the  can  is  apt  to  be  dirty  and  unfit 
for  use.  Milk  in  summer  from  an  open  can  in  a  shop  is 
never  fit  to  give  a  baby. 

Milk  from  a  herd  is  better  than  milk  from  one  cow. 

To   Keep   Milk. — Take  it  in  as   soon  as  delivered.     As 


528  DISEASES  OF  INFANTS  AND  CHILDREN. 

soon  as  possible  mix  the   baby's  milk.     Place  this  in  clean 
bottles  and  stopper  with  raw  cotton. 

Keep  the  milk  cold — on  ice  if  possible.  If  you  have  no 
ice,  wrap  a  cloth  wrung  out  in  cold  water  about  the  bottles. 

If  you  have  difficulty  in  keeping  milk,  bring  it  to  a  boil  as 
soon  as  it  is  delivered  to  you. 

Keep  the  things  for  the  baby's  milk  separate. 

Keep  the  things  clean. 

Scald  them  with  boiling  water  before  using. 
'  if  it  is  not  kept  cold ; 
if  it  is  not  kept  covered  ; 

^       1  if  it  has  been  put  in  dirty  bottles  or  cans ; 
if  it  is  measured  in  dirty  cans  ; 
.  if  it  gets  dust  in  it. 

DIRECTIONS   TO   MOTHERS   OF   MENTALLY  DEFECTIVE 

CHILDREN. 

The  improvement  will  be  slow,  and  no  one  can  tell  how 
much  it  will  be,  but  much  of  it  will  depend  on  teaching. 

The  child  should  have  as  much  out-door  life  as  possible, 
and  should  have  the  food  and  clothing  looked  after. 

Teach  the  child  to  do  some  simple  thing,  and  then  when  he 
can  do  that,  something  else. 

Do  not  try  to  teach  too  much  at  one  time,  nor  too  difficult 
things. 

Eventually  aim  to  teach  the  child  to  dress  and  undress 
itself,  to  keep  itself  clean,  to  control  the  bladder  and 
bowels,  to  avoid  disagreeable  habits  of  all  kinds. 

Give  the  child  simple  toys,  as  blocks  of  different  shapes, 
sizes,  and  colors,  and  later  various  kindergarten  games. 

Encourage  as  much  as  possible,  and  don't  let  other  chil- 
dren tease  or  discourage  the  child. 

Remember  not  to  lose  your  temper  with  the  child. 

If  possible,  get  a  teacher  of  the  feeble-minded  to  tell  you 
how  to  train  and  educate  the  child. 

Remember  that  all  of  these  things  require  the  greatest 
amount  of  patience. 


INFORMATION  FOR  POOR  IN  SUMMER. 


529 


An  Inexpensive  Home-made  Refrigerator. — Dr.  Alfred 
Hess,  of  New  York  [Journal  of  the  American  Medical  Asso- 
ciation, July  25,  1908,  p.  317),  has  devised  an  efficient  and 


Fig.  175. — Vertical  section  of  home-made  milk  refrigerator  :  S,  sawdust,  excelsior, 
or  other  cheap  non-conductor  of  heat  ;  T,  cylinder  of  tin  or  galvanized  iron  ;  C.  can 
in  which  is  placed  the  milk-jar.  M.  surrounded  by  broken  ice,  I ;  N,  newspapers 
nailed  to  lid  of  case.     (Hess,  in  Journal  of  American  Medical  Association.) 

cheap  refrigerator,  which  may  be  made  as  follows  :  An  ordi- 
nary packing  case,  measuring  at  least  13x18x11  inches, 
should   have  a  substantial  layer  of  sawdust  placed  in  the 


Fig.176.  —Horizontal  section  of  home-made  milk  refrigerator  :  M,  milk  container ; 
I,  broken  ice  ;  C,  can  for  holding  ice  ;  T,  tin  or  galvanized  iron  cylinder  to  prevent 
sawdust,  S,  from  falling  into  space  Avben  can  is  removed  for  purpose  of  emptying 
water,    i  Hess,  in  Journal  of  American  Medical  Association.) 

bottom.     On  this  set  a  tin  can,  eight  inches  in  diameter,  and 
tall  enough  to  hold  a  quart  milk  bottle,  and  around  this  place 

34 


530  DISEASES  OF  INFANTS  AND  CHILDREN. 

a  cylinder  of  tin  a  little  larger  in  diameter  than  the  can.  The 
cylinder  is  then  surrounded  by  sawdust,  the  lid  of  the  can  is 
left  free,  and  the  ice-box  is  completed  by  nailing  about  fifty 
layers  of  newspapers  to  the  lid  of  the  case.  Excelsior  may  be 
substituted  for  sawdust  if  desired.  If  the  case  is  shallow, 
several  layers  of  newspapers  may  be  placed  in  the  bottom  of 
it.  A  little  soda  may  be  put  in  the  can  every  day  to  prevent 
rusting.  This  refrigerator  will  keep  two  quart  bottles  or  four 
eight-ounce  feeding-bottles.  If  it  is  desired  to  keep  more 
bottles,  a  tin  can,  8|  inches  in  diameter,  with  a  slightly  larger 
case,  will  hold  the  wire  frame  usually  used  as  a  bottle-con- 
tainer. The  use  of  such  refrigerators  is  a  great  help  in  the 
homes  of  the  poor,  and  the  total  cost  is  only  from  25  to  50 
cents. 


LITERATURE.  531 

PEDIATRIC   LITERATURE. 

It  is  important  that  the  student  know  how  to  use  the 
information  which  has  been  collected  by  others  and  which  is 
preserved  in  medical  literature.  Nowadays  there  is  in  almost 
every  medical  center  one  or  more  well-equipped  medical 
libraries.  In  most  of  these  there  are  trained  librarians  who 
can  assist  the  student  in  finding  just  what  he  wants.  It 
frequently  happens,  however,  that  the  student  is  thrown  on 
his  own  resources,  and  the  following  hints  may  be  of  value 
how  to  proceed  in  looking  up  the  literature  on  any  given 
topic. 

To  find  the  older  literature  consult  the  Index  Catalogue  of 
the  Surgeon-General's  Library.  This  work  was  begun  in 
1880,  and  the  first  series,  in  sixteen  volumes,  completed  in 
1895.  In  1896  the  second  series  was  started,  and  up  to 
date  (1907)  ten  volumes  have  been  issued.  This  valuable 
work  will  be  found  in  every  good  working  library.  It  con- 
tains a  very  complete  list  of  books  and  monographs,  as  well 
as  numerous  references  to  journal  articles. 

To  find  the  more  recent  literature,  there  are  several  meth- 
ods of  procedure.  One  of  the  quickest  is  to  consult  some 
known  article  which  contains  a  list  of  references.  In  most 
instances  the  articles  referred  to  in  the  footnotes  of  this 
manual  contain  more  or  less  complete  bibliographies.  By 
referring  to  the  journals  mentioned  other  references  will 
usually  be  found.  The  most  certain  method  is  to  use  the 
Index  Jledicus.  This  is  a  publication  which  gives  a  classified 
list  of  all  medical  publications,  and  is  of  the  greatest  value. 
It  was  published  by  the  United  States  Government,  from  the 
Surgeon-General's  Library,  from  1879  until  April,  1899. 
Congress  failed  to  make  an  appropriation  for  it,  and  the  pub- 
lication ceased.  In  1900  the  French  undertook  a  work  on 
similar  lines — Bihliographia  Medica.  Three  volumes  of  this 
were  issued.  The  Carnegie  Institution  started  a  second 
series  of  the  Index  Medicus  in  1903,  and  the  French  journal 
was  discontinued.  The  Bibliograpkia  Medica  is  arranged  in 
the  same  way  as  the  Index  Medicus,  and  a  knowledge   of 


532  DISEASES   OF  INFANTS  AND   CHILDREN 

French  is  not  absolutely  essential  to  enable  one  to  find  the 
references.  It  is  not,  however,  very  complete  in  American 
journal  articles. 

The  Index  Medicus  has  a  very  complete  index  for  the 
bound  volumes,  both  of  subjects  and  of  authors.  By  making 
a  list  of  references  in  each  volume  a  complete  bibliography 
of  any  subject  may  easily  be  prepared.  The  current  numbers 
are  not  indexed  separately,  but  the  subjects  are  so  classified 
as  to  facilitate  finding  all  the  articles  mentioned. 

Information  on  any  topic  may  be  quickly  and  easily  found 
by  consulting  the  various  text-books  and  monographs,  espe- 
cially the  larger  works  on  pediatrics.  Of  these  latter  there 
is  one  in  English,  Keating' s  Cyclopedia  of  the  Diseases  of 
Children,  in  five  volumes.  There  is  a  very  complete  work  in 
German  in  a  number  of  volumes — Gerhardt's  Handbuch  der 
Kinderheilkunde.  In  French  there  is  the  excellent  five-vol- 
ume Traite  des  maladies  des  enfants,  edited  by  Grancher  and 
Comby,  the  second  edition  of  which  has  just  been  issued. 
The  work  of  Barthez  and  Sannee  is  a  perfect  treasure-house 
of  information,  but  is  available  only  to  those  who  read 
French. 

The  more  important  journals  on  the  diseases  of  children 
are  The  Archives  of  Pediatrics  and  Pediatrics,  in  America ; 
The  British  Journal  of  Diseases  of  Children,  in  England ; 
Archiv  fur  Kinderheilkunde,  Jahrbuch  fur  Kinderheilkunde, 
Centralblatt  fur  Kinderheilkunde,  Monatschrift  fur  Kinderheil- 
kunde, and  Der  Kinderarzt,  printed  in  German  ;  Archives  de 
medecine  des  enfants  and  Journal  de  clinique  et  de  therapeutique 
infantile,  in  French ;  and  La  Pediatria,  in  Italian. 


INDEX. 


Abdomen,  palpation  of,  46 
Abdominal  muscles,  152 
absence  of,  152 

pain,  41 
Abscess,  alveolar,  131 

of  brain,  330 

of  liver,  180 

peritonsillar,  139 

retro-esophageal,  142 

retropharyngeal,  140 
from  Pott's  disease,  141 
idiopathic,  141 
Absence,  congenital,  of  abdominal 

muscles,  152 
Acetonuria,  258 
Achondroplasia,  350 
Acid  intoxication,  119 

urine,  drugs  to  render,  498 
Acquired  syphilis,  440 
Acute  arthritis,  462 

ascending  paralysis,  360 

hydrocephalus,  432 

infectious  diseases,  370 

wasting  paralysis,  419 

yellow  atrophy,  180 
Addison's  disease,  251 
Adenia,  246 
Adenitis,  acute,  248 

chronic,  249 

syphilitic,  250 

tuberculous,  435 
Adenoids,  184 

facial  expression  in,  37 

in  school  children,  510 
Adenoma  of  umbilicus,  68 
Adherent  prepuce,  271 
Adolescent  rachitis,  123 
Adrenals,  251 

hemorrhage  into,  251 
Air,  fresh,  482 

for  baby  in  summer,  526 

hunger,  120 


Airing,  21 

Alabaster  cachexia,  266 

Alalia,  315 

Albumin  milk,  93 

Albuminuria,  cyclic,  255 

functional,  255 

physiologic,  255 
Alcohol,  485 
Alopecia  areata,  286 
Alphabet,  Wyllie's  physiologic,  316 
Alteratives,  488 
Alveolar  abscess,  131 
Amaurosis,  39 

Amaurotic  family  idiocy,  341 
Amebic  colitis,  164 
Ammonia,  aromatic  spirit  of,  496 
Ammonium  acetate,  493 

chlorid,  494 
Amyloid    degeneration    of    intes- 
tines, 163 
of  kidney,  266 

liver,  179 

spleen,  252 
Amyotrophic  lateral  sclerosis,  362 
Anaemia       infantum       pseudoleu- 

caemica,  241 
Anatomic  peculiarities,  20 
Anemia,  lymphatic,  246 

pernicious,  238 

secondary,  239 

splenic,  241 
Anesthetics,  483 
Aneurysm,  230 
Anginoid  scarlet  fever,  373 
Angioneurotic  edema,  47,  320 
Ankylostomiasis,  455 
Antacids,  496 
Anterior  poliomyelitis,  419 
Anthelmintics,  496 
Antimalarial  remedies,  499 
Antimony  and  potassium  tartrate, 

494 

533 


534 


INDEX. 


Antipyretic  drugs,  483 
Antipyretics,  481 
Antirheumatic  remedies,  497 
Antiseptics,  urogenital,  498 
Antispasmodics   for   whooping- 
cough,  498 
Anuria,  258 
Anus,  fissure  of,  175 

irritation  of,  175 

prolapse  of,  174 
Aortic  insufficiency,  227 

regurgitation,  227 

stenosis,  226 
Aphasia,  functional,  316 
Aphthae,  Bednar's,  132 
Aphthous  stomatitis,  133 
Appendicitis,  168 
Arching,  high,  of  palate,  40 
Arms,  pain  in,  42 
Arnold  sterilizer,  96 
Aromatic  spirit  of  ammonia,  496 

water,  490 
Aromatic  spirit  of  ammonia,  496 

waters,  490 
Arsenic,  488 
Arterial  hypoplasia,  230 
Arthritis,  acute,  of  infants,  462 

associated  with  hemophilia,  470 

deformans,  461 

gonorrheal,  468 

meningococcal,  469 

pneumococcal,  470 

tuberculous,  463,  469 
Articular  ostitis  of  hip,   tubercu- 
lous, 465 
of  knee,  tuberculous,  468 
Artificial  feeding,  76 

respiration,    Laborde's   method, 
52 
Schultze's  method,  51,  52 
Ascaris  lumbricoides,  172,  173 
Ascites,  177 

chlyous,  178 
Asphyxia,  50 
Aspirin,  497 

Asthenic  bulbar  paralysis,  337 
Asthma,  197 

thymic,  250 
Astringents,  496 
Asylums,  infant,  feeding  in,  106 
Asymmetry  of  chest,  34 
Ataxia,  300 


Ataxia,  cerebellar  hereditary,  359 

Friedreich's,  358 

hereditary,  358 
Atelectasis,  congenital,  52 
Atheroma,  230 
Athetoid  movements,  309 
Athetosis,  309 
Athrepsia,  115 
Atomizer,  steam,  188 
Atrophies  of  nervous  origin,  360 
Atrophy,  acute  yellow,  180 

peroneal  muscular,  365 

progressive  central  muscular,  360 
neuritic  muscular,  365 

simple,  115 
Atropin,  487 
Aura,  303 
Auvard  incubator,  35 


Bacillus  coli  communis  therapy, 

507 
Back,  31 

Backhaus'  milk,  94 
Backwardness,  316 
Balanitis,  272 
Balsam  of  tolu,  494 
Baner's  method,  91 
Barlow's  disease,  124 
Barrel-shaped  chest,  33 
Basedow's  disease,  320 
Basham's  mixture,  493 
Basilar  meningitis,  432 
Bath,  bran,  503 

cold,  481 

evaporating,  482 

hot,  503 

hot-air,  503 

mustard,  504 

salt,  503 

soda,  503 

starch,  503 

temperature  of,  18 
Bathing,  17 

of  baby  in  summer,  526 
Bean,  soy,  94 
Bednar's  aphthse,  132 
Belladonna,  487 
Bell's  palsy,  368 
Bifid  palate,  130 

tongue,  130 
Bile,  flow  of,  interference  with,  49 


INDEX. 


535 


Bile-ducts,  malformations  of,  54 
Binet  and  Simon's  scale  for  measur- 
ing intelligence,  518-525 
Birth  palsies,  323 
Bismuth,  496 
Bitter  wine  of  iron,  488 
Black  measles,  379 

stools,  107,  108 
Blackish-brown  stools,  108 
Bladder,  31 

calculi  in,  274 

diseases  of,  274 

exstrophy  of,  271 

spasm  of,  274 

training  of,  19 
Bleeder's  disease,  242 
Blind  children,  training  of,  26 
Blindness,  39 

word,  congenital,  26,  39 
Blood  in  infancy  and   childhood, 
231 

in  stools,  49 

in  urine,  256 
Blood-cells,  red,  235 
nucleated,  231 
number  of,  231 

white,  231,  235 
abnormal,  233 
Blood-changes  in  congenital  cyan- 
osis, 237 

in  diphtheria,  236 

in  disease,  236 

in  meningitis,  237 

in  pneumonia,  236 

in  scarlet  fever,  236 

in  whooping-cough,  237 

significance  of,  235 
Blood-dust,  235 
Blood-plates,  234 
Blood-vessels,  diseases  of,  230 
Boils,  283 

Bones,  diseases  of,  471 
Bothriocephalus  latus,  172 
Bottle,  nursing,  hygienic,  95 
Bottle-fed  baby,  care  of,  in  sum- 
mer, 527 
Bottle-feeding,  76 

beginning,  94 
Bottles,  care  of,  in  summer,  527 
Bowels,  inflammation  of,  161 

training  of,  19 
Brain,  abscess  of,  330 


Brain,  inflammation  of,  326 

malformations  of,  320 

tumor  of,  331 

water  on,  331,  432 
Bran  bath,  503 
Breast,  pigeon,  34 
Breast-feeding,  69 
Breast-pump,  70 
Breasts,  29 
Breath,    shortness    of,    in    school 

children,  515 
Breck   feeder  for  premature   and 

weak  infants,  35 
Bright's  disease,  acute,  261 
Bromids,  485 
Bromipin,  485 
Bromoform,  498 
Bronchi,  diseases  of,  193 
Bronchial    lymph-nodes,    tubercu- 
losis of,  436 
Bronchiectasis,  195 
Bronchitis,  193 

acute  catarrhal,  193 

capillary,  202 

chronic,  195 

fibrinous,  195 

tuberculous,  432 
Bronchopneumonia,  199 

acute,  congestive  form,  202 

chronic,  208 

secondary,  202 
Buhl's  disease,  62 
Bulging  of  anterior  fontanel,  38 
Buttermilk,  93 


Cachectic  thrombosis,  330 
Calculi,  renal,  269 

vesical,  274 
Calmette's    test    for   tuberculosis, 

427 
Calomel,  491 
Caloric  needs  of  infants,  79 

Fraley's  method  of  determin- 
ing, 80 

value  of  modified  milk,   deter- 
mination of,  79 
Camphor,  486 
Camphorated  oil,  503 
Cancrum  oris,  135 
Capillary  bronchitis,  202 
Carcinoma  of  stomach,  151 


536 


INDEX. 


Care  of  cord,  17 

of  eyes,  17 

of  genital  organs,  19 

of  mouth,  18 

of  nervous  system,  20 

of  newborn,  17 

of  skin,  19 

of  teeth,  18 
Caries  of  spine,  463 
Carrier,  disease,  370 
Carron  oil,  501 
Cascara  sagrada,  492 
Castor  oil,  491 
Catarrh,  chronic  gastric,  148 

nasal,  183 
Catarrhal  appendicitis,  169 

bronchitis,  acute,  193 

croup,  187 

fever,  acute,  424 

jaundice,  153 

laryngitis,  acute,  189 

pneumonia,  199 

spasm  of  larynx,  187 

stomatitis,  133 
Cathartics,  491 
Cells,  mast,  233,  236 
Cephalhematoma,  63 
Cerebellar  hereditary  ataxia,  359 
Cerebral  infantile  paralysis,  334 

paralysis,  323 

tumors,  331 
Cerebrospinal  fever,  327,  413 
Cerium  oxalate,  491 
Cervical  opisthotonos,  311 
Cestodes,  171 
Chalk  mixture,  496 
Chapin's  milk-dipper,  83 
Charcot-Marie  atrophy,  365 
Charcot's  disease,  362 
Cheesy  pneumonia,  429 
Chest,  25 

asymmetry  of,  34 

barrel-shaped,  33 

contracted,  34 

deformities  of,  33 

flattened,  34 

funnel-shaped,  34 
Chicken-pox,  385 

in  school-children,  515 
Childhood,  anatomic  peculiarities 
of ,  20 

physiologic  peculiarities  of,  20 


Children,  examination  of,  36 

Chills,  43 

Chloral  hydrate,  485 

Chlorosis,  237 

Cholera  infantum,  157,  159 

Chorea,  307 

hereditary,  312 

Huntington's,  312 

in  school  children,  512 

Sydenham's,  307 
Chvostek's  sign,  299 
Chylous  ascites,  178 
Circulation,  214 

Circumscribed  edema,  acute,  47 
Cirrhosis  of  liver,  180 
Citrate  of  magnesia,  492 
Clark's  rule  for  dosage,  477 
Cleft  palate,  129 
Cleidocranial  dystosis,  352 
Climate,  changes  in,  482 
Closure  of  anterior  fontanel,  38 
delay  in,  38 

of  fontanels,  22 

of  sutures,  22 
Clothing,  18 

for  baby  in  summer,  526 
Clubbing  of  fingers,  48 
Cod-liver  oil,  487 
Cold  bath,  481 

in  head,  182 

pack,  481 

sponge,  481 
Colic,  110 

intestinal,  165 
Colitis,  amebic,  164 
Colles'  law,  441 
Colon,  dilatation  of,  170 

hypertrophy  of,  170 

irrigation  of,  501 
Colostrum,  70 
Coma,  297 

diabetic,  127 
Comfort  of  child,  483 
Composition  of  cows'  milk,  77 
Compression  myelitis,  357 
Condensed  milk,  93 
Congenital  atelectasis,  52 

heart  disease,  217 

myotonia,  310 

stenosis  of  pylorus,  150 

syphilis,  441 
Congestion,  acute,  of  liver,  179 


INDEX. 


537 


Congestion  of  kidney,  260,  261 
of  spleen,  252 

Conjunctival  test  for  tuberculosis, 

427 
Constipation,  chronic,  166 
Contracted  pupils,  39 
( 'nnvulsions,  301 
Convulsive  tic,  313 
Cord,  care  of,  17 
Corrosive  esophagitis,  143 
Coryza,  182 
Cough  in  school  children,  514 

mixtures,  493 

nervous,  197 

reflex,  197 
Counterirritants,  503 
Cowling's  rule  for  dosage,  477 
Cow-pox,  388 

Cows'  milk,  composition  of,  77 
Craniotabes,  38 
Cranium,  natiform,  25 
Cream  of  tartar,  493 
Creole's  method  of  preventing  oph- 
thalmia neonatorum,  56 
Creeping  pneumonia,  207 
Creosotal,  495 
Creosote,  495 
Cretinism,  346 
Croup,  catarrhal,  187 

false,  187 

kettle,  188 

spasmodic,  187 

tent,  187 

true,  190 
Croupous  pneumonia,  205 

tonsillitis,  137 
Cry,  41 

hydrocephalic,  41 
Cryptorchidism,  271 
Cutaneous    test    for    tuberculosis, 

427 
Cvanosis,congenital,  blood-changes 

in,  237 
Cyclic  albuminuria,  255 

vomiting,  144 
Cyst,  omental,  178 
Cystitis,  268,  275 
Cystopyelitis,  268 
Cysts,  hydatid,  of  liver,  180 

Dactylitis,  48 
Day  terrors,  314 


Deaf    and    dumb    children,    early 

t  raining  of,  27 
Deaf-mutism,  354 
Deafness,  40 
Death,  sudden,  49 
Defective  children,  mentally,  528 
Defects,   physical,   in  school  chil- 
dren, 513 
Deficient  children,  morally,  345 
Deformities  of  chest,  33 

of  hands,  48 

of  rectum,  152 

of  tongue,  130 
Degeneration,    amyloid,    of   intes- 
tines, 163 
of  kidney,  266 

fatty,  of  newborn,  62 

stigmata  of,  353 
Delicate  infants,  34 
Delirium,  296 
Dentition,  difficult,  131 
Depression  of  anterior  fontanel,  38 
Deprivation,  idiocy  by,  339 
Dermatitis  venenata,  280 
Dermatomycosis  tricophytina,  290 
Desquamation,        epithelial,        of 

tongue,  130 
Development,  muscular,  25 

of  intelligence  of  children,  meas- 
uring, 518-525 
Developmental  paralysis,  352 
Diabetes  insipidus,  259 

meUitus,  126 
Diabetic  coma,  127 
Diaceturia,  258 
Diapers,  care  of,  527 
Diaphoretics,  493 
Diaphragmatic  hernia,  66 
Diarrhea,  154 

drugs  useful  in,  496 

facial  expression  in,  38 

summer,  157 
Diarrheal  diseases,  infectious,  157 
Diathesis,  hemorrhagic,  242 
Diet,  forbidden,  101 

of  school  children,  102 

two  and  one-half  to  six  years,  100 
Dietetic  errors,  108 
Difficult  detention,  131 
Digestants,  491 
Digit alin,  Merck's,  486 
Digitalis,  487 


538 


INDEX. 


Dilatation  of  colon,  170 

of  stomach,  149 
Dilated  pupils,  39 
Diphtheria,  396 

blood-changes  in,  237 

danger  after  exposure  to,  516 

in  school  children,  510,  515 

intubation  in,  407 

laryngeal  obstruction  in,  treat- 
ment, 406 

return  to  school  after,  517 

tracheotomy  in,  409 
Diphtheritic  paralysis,  368 
Diplegia,  spastic,  334 
Discharge,  nasal,  acute,  40 
Disease  carrier,  370 
Diseases  of  bladder,  274 

of  blood-vessels,  230 

of  bones,  471 

of  bronchi,  193 

of  ductless  glands,  246 

of  intestines,  152 

of  joints,  461 

of  kidneys,  259 

of  larynx,  187 

of  liver,  179 

of  lungs,  193 

of  mouth,  128 

of  nervous  system,  296 

of  newborn,  50 

of  nutrition,  114 

of  pharynx,  128 

of  rectum,  174 

of  skin,  277 

of  spinal  cord,  355 

of  stomach,  144 

of  thymus  gland,  250 

of  tonsils,  137 

of  uvula,  132 

pyogenic,  54 
Disposition,  change  in,  296 
Diuretics,  492 
Diuretin,  493 
Diverticulum,  Meckel's,  152 

tumor,  68 
Dizziness,  297 
Dosage,  476 

table  of,  478-480 
Dover's  powder,  494 
Drowsiness,  297 

in  school  children,  514 
Drug  eruptions,  293 


Duchenne-Aran  type  of  muscular 

atrophy,  362 
Duchenne's  dystrophy,  363 
Ductless  glands,  diseases  of,  246 
Dumb    and    deaf    children,    early 

training  of,  27 
Duotal,  495 
Dwarfism,  351 
Dysentery,  161 

chronic,  162 
Dyspnea,  46 

Dystosis,  cleidocranial,  362 
Dystrophia  adiposogenitalis,  253 
Dystrophy,  progressive  muscular, 

362 


Ears,  40 

examination  of,   in  school  chil- 
dren, 509 
Ecthyma,  285 
Eczema,  278 

in  school  children,  510 
Edema,  47,  68 

angioneurotic,  47,  320 

circumscribed,  acute,  47 

general,  47 

of  face,  47 

of  glottis,  190 
Effervescing  draughts,  490 
Effusions,  pleural,  46 
Electrical  reactions,  300 
Elongated  uvula,  132 
Emaciation  in  school  children,  515 
Embolism,  230 
Emphysema,  209 
Empyema,  212 
Encephalocele,  321 
Endocarditis,  222 

acute,  222 

malignant,  224 

ulcerative,  224 
Enema,  502 
Enlarged  thyroid,  320 
Enlargement  of  spleen,  252 
Enteric  fever,  409 
Enteritis,  161 
Enterocolitis,  161 
Enuresis,  274 
Eosinophils,  233 
Eosinophilia,  236 
Eosinophilic  myelocytes,  234 


INDEX. 


539 


Epidemic  cerebrospinal  meningitis, 
413 

hemoglobinuria,  62 

parotitis,  394 

pneumococcic  infections,  425 

roseola,  381 
Epilepsy,  303 

in  school  children,  513 

Jacksonian,  303 

psychic,  303 
Epileptic  idiocy,  339 
Epiphysitis,  acute,  462 
Epispadias,  271 

Epithelial  desquamation  of  tongue, 
130 

pearls,  40 
Epsom  salts,  491 
Erb-Goldflam  syndrome,  337 
Erb's  dystrophy,  363 

paralysis,  324 
Ergot,  498 
Errors,  dietetic,  108 
Eruption  of  permanent  teeth,  28 

of  temporary  (milk)  teeth,  27 
Eruptions,  drug,  293 
Erythema  infectiosum,  384 
Erythrocytes,  235 

nucleated,  231 

number  of,  231 
Escharotics,  501 
Esophagitis,  142 

corrosive,  143 
Esophagus,  inflammation  of,  142 

malformations  of,  143 
Essential  paralysis  of  children,  419 
Estraus  Materna  Graduate,  87 
Euquinin,  499 
Evaporating  bath,  482 
Examination   of   nervous   system 
296 

of  school  children,  508 

of  sick  children,  36 

of  stools,  48 
Exercise,  20 

Exophthalmic  goiter,  320 
Exostoses,  multiple,  471 
Expectorants,  493 
Exstrophy  of  bladder,  271 
Eyes,  care  of,  17 

examination  of,   in  school  chil- 
dren, 508 

running,  in  school  children,  514 


Face,  edema  of,  47 

flushing  of,   in  school  children, 

514 
swelling  of,   in  school  children, 

514 
tapir,  362 
Facial  expression,  37 
in  adenoids,  37 
in  diarrhea,  38 
in  meningitis,  38 
in  nephritis,  38 
in  pneumonia,  38 
in  vomiting,  38 
paralysis,  368 
of  newborn,  326 
Factors  in  infant  feeding,  106 
Falling  sickness,  303 
False  croup,  187 
membrane,  398 
meningocele,  322 
Family  jaundice,  chronic,  180 
Farinaceous  gruels,  93 
Fat  of  milk,  78 

Fatty   degeneration    of    newborn, 
62 
liver,  179 
Favus,  291 

in  school  children,  514 
Feces.     See  Stools. 
Feeble-mindedness,  337 
Feeding,  artificial,  76 
bottle-,  76 

beginning,  94 
by  stomach-tube,  111 
in  infant  asylums,  106 
laboratory,  80 
mixed,  76 
nasal,  113 

of  delicate  infants,  34 
of  infants,  69 
of  premature  infants,  34 
of  sick  infants,  109 
second-year,  94 
Ferrosomatose,  488 
Fetal  myxedema,  350 

rickets,  350 
Fever,  inanition,  68 
Fibrinous  bronchitis,  195 
Fingers,  clubbing  of,  48 
Fish-skin  disease,  277 
Fissure  of  anus,  175 
Floating  spleen,  253 


540 


INDEX. 


Flushing  of  face  in  school  children, 

514 
Follicular  stomatitis,  vesicular,  133 

tonsillitis,  137 
Fontanel,  anterior,  bulging  of,  38 
closure  of,  38 
delay  in,  38 
depression  of,  38 
examination  of,  38 
systolic  murmur  over,  38 
tension  of,  38 
Fontanels,  closure  of,  22 
Food  intoxications,  118 
Foreign  bodies  in  larynx,  191 
Fourth  disease,  387 
Fraley's    method    of    determining 

caloric  needs  of  infants,  80 
Freeman's  pasteurizer,  96 
Frenum,  ulcer  of,  131 
Fresh  air,  482 

for  baby  in  summer,  526 
Friedreich's  ataxia,  358 
Frohlich's  syndrome,  253 
Functional  albuminuria,  255 
aphasia,  316 
heart  disorders,  229 
murmurs,  229 
Funnel-shaped  chest,  34 
Furunculosis,  283 


Gall-stones,  180 
Gangrene,  292 

of  lung,  209 
Gangrenous  appendicitis,  169 

stomatitis,  135 

vulvitis,  275 
Gartner's  milk,  94 
Gastralgia,  145 
Gastric  catarrh,  chronic,  148 

indigestion,  acute,  146 
chronic,  148 
Gastritis,  acute,  147 

chronic,  148 
Gastroduodenitis,  153 
Gastro-enteritis,  acute,  157 
Gaucher' s  disease,  253 
Gavage,  111 
Genetous  idiocy,  338 
Genital  organs,  271,  272 
care  of,  19 
malformations  of,  271 


German  measles,  381 

danger  after  exposure  to,  516 
return  to  school  after,  517 
Giant  purpura,  244 

urticaria,  47 
Gigantoblasts,  231 
Glands,  lachrymal,  29 

salivary,  29 

sebaceous,  29 

sweat,  29 

thymus,  31 
Glomerulonephritis,  262 
Glossitis,  130 
Glosso-labial-laryngeal     paralysis, 

362 
Glottis,  edema  of,  190 
Glycosuria,  256 
Goiter,  exophthalmic,  320 
Gonococcus  vaccines,  506 
Gonorrheal  arthritis,  468 
Graduate,  Materna,  86 
Grand  mal,  303 
Granuloma  of  umbilicus,  67 
Graves'  disease,  320 
Green  sickness,  237 

stools,  108 
Ground  itch,  455 
Growth,  rate  of,  in  height,  23 
Gruels,  farinaceous,  93 

malted,  92 
Guaiacol,  495 


Habit  spasm,  309 

in  school  children,  512 
Habits,  injurious,  319 
Hand,  trident,  351 
Hands,  48 

deformities  of,  48 

shape  of,  48 

swelling  of,  in  school  children, 
514 
Harelip,  128 
Harrison's  sulcus,  34 
Head,  retraction  of,  311 

shape  of,  25 

size  of,  25 
Headache,  313 
Hearing,  27 
Heart,  214,  215 

disease,  congenital,  217 

disorders,  functional,  229 


INDEX. 


541 


Heat-rash,  281 
Height,  22,  23 
Hematemesis,  151 

Hematoma  of  sternomastoid,  64 
Hematuria,  256 
Hemic  murmurs,  229 
Hemiplegia,  334 
Hemoglobin,  231,  235 
Hemoglobinuria,  256 

epidemic,  62 
Hcmopericardium,  221 
Hemophilia,  242 

arthritis  associated  with,  470 
Hemorrhage  from  stomach,  151 

into  adrenals,  251 

of  newborn,  63 

spontaneous,  64 

traumatic,  63 

visceral,  64 
Hemorrhagic  diathesis,  242 

disease  of  newborn,  64 

purpura,  244 
Hemorrhoids,  175 
Henoch's  purpura,  245 
Hepatitis,  syphilitic,  54 
Hereditary  ataxia,  358 

chorea,  312 

syphilis,  441 
late,  443 
Hernia,  diaphragmatic,  66 

umbilical,  67 
Heroin,  495 
Herpes  of  vulva,  272 
Herpetic  stomatitis,  135 
Hexamethylenamin,  498 
Hiccough,  310 
High-grade  imbeciles,  345 
Hip- joint  disease,  465 
Hippus,  39 
Hives,  285 

Hodgkin's  disease,  246 
Holt's  percentage  milk  method  of 

modifying  milk,  86 

table  as  guide  in  breast-feeding, 
73 
Hook-worm  disease,  455 
Horseshoe  kidney,  259 
Hot  bath,  503 

pack,  503 
Hot-air  bath,  503 
Hunch  back,  464 
Hunger,  air-,  120 


Huntington's  chorea,  312 
Hutchinson's  teeth,  448 
Hydatid  cysts  of  liver,  180 
Hydrencephalocele,  321,  322 
Hydrocele,  272 
Hydrocephalic  cry,  41 

idiocy,  338 
Hydrocephalus,  332,  333 

acute,  432 
Hydronephrosis,  270 
Hydropericardium,  221 
Hygiene,  school,  508 
Hygienic  nursing  bottle,  92 
Hymenolepis  nana,  172 
Hyoscyamus,  487 
Hyperemia  of  kidney,  260,  261 
Hyperpyrexia,  45 
Hypertrophic  interstitial  neuritis, 

365 
Hvpertrophv,    chronic,   of  tonsils, 
140 

congenital,  of  tongue,  130 

of  colon,  170 
Hypoplasia,  arterial,  230 
Hypospadias,  271 
Hypostatic  pneumonia,  207 
Hysteria,  312 

in  school  children,  513 


Ice-bags,  481 

Ichthyol,  501 

Ichthyosis,  congenital,  277 

Icterus,  53,  179 
catarrhal,  153 
chronic  family,  180 

Idiocy,  337 

amaurotic  family,  341 
by  deprivation,  339 
epileptic,  339 
genetous,  338 
hydrocephalic,  338 
inflammatory,  339 
microcephalic,  338 
Mongolian,  339 
paralytic,  339 

Idioglossia,  316 

Ileocolitis,  acute,  161 
chronic,  162 

Imbecility,  337 
high-grade,  345 

Imperial  drink,  493 


542 


INDEX. 


Impetigo  contagiosa,  283 

in  school  children,  514 
Inanition,  114 

fever,  68 
Incontinence  of  feces,  176 

of  urine,  274 
Incubator,  Auvard,  35 
Indicanuria,  257 
Indigestion,  acute  gastric,  146 
intestinal,  155 

chronic  gastric,  148 
intestinal,  164 
Infancy,  anatomic  peculiarities  of, 
20 

physiologic  peculiarities  of,  20 
Infant  asylums,  feeding  in,  106 

feeding,  69 

other  factors  in,  106 
Infantile  cerebral  paralysis,  334 

myxedema,  346 

spinal  paralysis,  419 
Infantilism,  349 
Infants,  caloric  needs  of,  79 

delicate,  34 

feeding  of  sick,  109 

premature,  34 

stools,  106 
Infarctions,  uric-acid,  260 
Infections,  acute,  54 

epidemic  pneumococcic,  425 

septic,  54 
Infectious  diarrheal  diseases,  157 

diseases,  370 

in  school  children,  515 

danger  after  exposure,  516 
return  to  school  after,  517 
transmission  of,  370 
Inflammation,  local,  remedies  for, 
501 

of  bowels,  161 

of  brain,  326 

of  esophagus,  142 

of  kidney,  261 

of  lungs,  205 
Inflammatory  idiocy,  339 

thrombosis,  330 
Influenza,  424 
Inhalations,  505 
Injurious  habits,  319 
Insanity,  352 
Insufficiency,  aortic,  227 

mitral,  225 


Insufficiency,  tricuspid,  227 
Intelligence,  development  of,  meas- 
uring, 518-525 
Interstitial    pneumonia,     chronic, 

208 
Intertrigo,  278 
Intestinal  colic,  165 

indigestion,  acute,  155 
chronic,  164 

intoxication,  acute,  157 

obstruction,  65 

worms,  171 
Intestines,  31 

amyloid  degeneration  of,  163 

diseases  of,  152 

malformations  of,  152 

tuberculosis  of,  437 
Intoxication,  acid,  119 

acute,  intestinal,  157 

food,  118 
Intubation  in  diphtheria,  407 
Intussusception,  167 
Iodin,  489 
Iodoglycerin,  489 
Ipecacuanha,  493 
Iron,  488 

Irrigation  of  colon,  501 
Irritability,  295 
Irritation  of  anus,  175 
Itch,  289 

ground,  455 


Jacksonian  epilepsy,  303 
Jaundice,  53,  179 

catarrhal,  153 

chronic  family,  180 
Joints,  congenital  syphilis  of,  470 

diseases  of,  461 
Juvenile  general  paralysis,  352 

myxedema,  346 


Keratoma  diffusum,  277     ■ 
Kernig's  sign,  298 
Kidney,  amyloid  degeneration  of, 
267 

calculi  in,  269 

congestion  of,  260,  261 

diseases  of,  259 

horseshoe,  259 

hyperemia  of,  260,  261 


INDEX. 


543 


Kidney,  inflammation  of,  261 
lardaceous,  266 
malformations  of,  259 

malpositions  of,  259 

new  growths  in,  267 

sarcoma  of,  267 

tuberculosis  of,  440 

waxy,  266 
Kink  cough,  390 
Knee,  inner  side,  pain  in,  41 
Knee-jerk,  297 
Koch's  old  tuberculin,  507 
Koplik's  spots  in  measles,  377 


La  grippe,  424 
Laboratory  feeding,  80 
Laborde's     method     of     artificial 

respiration,  52 
Lachrymal  glands,  29 
Ladd's  table,  91 
Lalling,  315 

Landouzy-Dejerine  dystrophy,  363 
Landry's  paralysis,  360,  420 
Lardaceous  kidney,  266 
Laryngeal  defects,  318 

monotony,  318 

obstruction  in  diphtheria,  treat- 
ment, 406 

stridor,  congenital,  192 
Laryngismus  stridulus,  306 
Laryngitis,  acute  catarrhal,  189 

chronic,  190 

membranous,  190 

spasmodic,  187 

syphilitic,  191 

tuberculous,  190 
Larynx,  catarrhal  spasm  of,  187 

diseases  of,  187 

foreign  bodies  in,  191 

papilloma  of,  191 

tumors  of,  191 
Lassar's  paste,  500 
Late  hereditary  syphilis,  448 
Law,  Colles',  441 

Warner's,  of  coincident  develop- 
ment, 343 
Legs,  pain  in,  42 

swelling  of,  in  school  children, 
514 
Leichtenstern's  phenomena,  416 
Leukemia,  240 


Leukocytes,  231,  235 

abnormal,  233 

degenerated,  234 

frequency  of  various  forms,  235 

mononuclear,  231 

polymorphonuclear  neutrophilic, 
233 
Leukocythemia,  240 
Leukocytosis,  235 

mixed,  240 
Leukopenia,  236 
Lice  in  school  children,  514 
Lichen  tropicus,  281 
Licorice,  495 
Liniments,  504 
Lip  reflex  of  newborn,  299 
Liquor  ammonii  acetatis,  493 
Lisping,  315 

Literature,  pediatric,  531 
Lithuria,  257 
Liver,  31 

abscess  of,  180 

acute  congestion  of,  179 
yellow  atrophy,  180 

amyloid.  179 

cirrhosis  of,  180 

diseases  of,  179 

fatty,  179 

hydatid  cysts  of,  180 
Lobar  pneumonia,  205 
Lobular  pneumonia,  199 
Loss  of  weight,  109 
Lousiness,  288 
Lumbar  puncture,  46,  417 
Lung,  diseases  of,  193 

fever,  205 

gangrene  of,  209 

inflammation  of,  205 
Lymphadenoma,  246 

of  stomach,  151 
Lymphatic  anemia,  246 
Lymphatism,  247 
Lymphocytes,  231,  235 
Lymphocytosis,  235 
Lymph-nodes,  42 

bronchial,  tuberculosis  of,  436 

mesenteric,  tuberculosis  of,  439 

tuberculosis  of,  435 


Macroglossia,  129 
Magnesia,  491 


544 


INDEX. 


Magnesia,  citrate  of,  492 

milk  of,  491 

sulphate  of,  491 
Maladie  bronzee,  62 
Malaria,  451 
Malformations  of  bile-ducts,  54 

of  brain,  320 

of  esophagus,  143 

of  genital  organs,  271 

of  intestines,  152 

of  kidney,  259 

of  spinal  cord,  355 
Malignant  endocarditis,  224 

scarlet  fever,  373 
Malnutrition,  117 
Malpositions  of  kidney,  259 
Malted  gruels,  90 
Manna,  492 
Marasmus,  115 
Massage,  482 
Mast  cells,  233,  236 
Mastitis,  66 
Masturbation,  319 
Materna  glass,  89 

graduate,  87 
Maynard  Ladd's  table,  91 
Measles,  375 

danger  after  exposure  to,  516 

German,  381 

danger  after  exposure  to,  516 
return  to  school  after,  517 

in  school  children,  510,  515 

return  to  school  after,  517 
Meckel's  diverticulum,  152 
Meconium,  70 
Megaloblasts,  231 
Megalocytes,  231 
Membranous  laryngitis,  190 

rhinitis,  184 
Meningitis,  acute,  327 

basilar,  432 

blood-changes  in,  237 

chronic  basilar,  328 

epidemic,  413 

facial  expression  in,  38 

posterior  basic,  328 

spinal,  356 

tuberculous,  432 
Meningocele,  321,  355 

false,  322 
Meningococcal  arthritis,  468 
Meningococcus  vaccines,  506 


Meningomyelocele,  355 

Mental  development  of  children, 

measuring,  518-525 
Mentally  defective  children,  528 

school  children,  511 
Merck's  digitalin,  486 
Mercurial  teeth,  29 
Mercury,  488 

Mesenteric    lymph-nodes,     tuber- 
culosis of,  439 
Microcephalic  idiocy,  338 
Microcytes,  231 
Miliaria,  281 
Milk,  albumin,  93 

Backhaus',  94 

care  of,  in  summer,  527 

condensed,  93 

cows',  composition  of,  77 

crust,  279,  282 

Gartner's,  94 

modification,  80 

modified,    caloric    value,    deter- 
mination of,  79 

of  magnesia,  491 

preparation  of,  96 

prescriptions,  81 

reaction  of,  79 

technic  of  modifying,  95 

teeth,  eruption  of,  28 

tests  for,  74 
Milk-dipper,  Chapin's,  83 
Minor    symptoms,    treatment    of, 

483 
Mitral  insufficiency,  225 

regurgitation,  225 

stenosis,  226 
Mixed  feeding,  76 
Modification  of  milk,  80 
Modified  milk,   caloric  value,  de- 
termination of,  79 
Mongolian  idiocy,  339 
Mononuclear  leukocytes,  231 
Moorehouse's    method    of    deter- 
mining caloric  value  of  modified 

milk,  80 
Morally  deficient,  345 
Morbus  coxarius,  465 

maculosus  Werlhofii,  244 
Moro's  test  for  tuberculosis,  428 
Mouth,  care  of,  18 

diseases  of,  128 
Mucous  polypus  of  umbilicus,  68 


INDEX. 


545 


Mucus  in  stools,  48 
Muguet,  133 
Multiple  exostoses,  471 

neuritis,  366 
Mumps,  394 

danger  after  exposure  to,  516 

in  school  children,  516 

return  to  school  after,  517 
Murmur,    systolic,    over    anterior 

fontanel,  38 
Murmurs,  functional,  229 

hemic,  229 
Muscles,  46 

abdominal,    congenital    absence 
of,  152 
Muscular  atrophies,  360 

atrophy,  peroneal,  365 
progressive  neuritic,  365 

development,  25 

dystrophies,  362 

pseudohypertrophy,  363 
Mustard  bath,  504 

pack,  504 

plaster,  503 
Myasthenia  gravis,  337 
Myatonia,  46 

congenita,  46 
Myelitis,  356 

compression,  357 
Myelocytes,  233,  236 

eosinophilic,  234 

non-granular,  234 
Myocarditis,  228 
Myotonia,  congenital,  310 
Mvxedema,  fetal,  350 

fruste,  348 

infantile  or  juvenile,  346 

Nasal  catarrh,  chronic,  183 

diphtheria,  401 

discharge,  acute,  40 

feeding,  113 

speech,  315 

sprays,  505 

washes,  505 
Natiform  cranium,  25 
Neck,  swelling  of,  in  school  chil- 
dren, 515 
Nematodes,  173 
Nephritis,  acute,  261 

chronic,  264 

35 


Nephritis,  desquamative,  261 

diffuse,  261,  262 

facial  expression  in,  38 

parenchymatous,  261,  262 

tubular,  acute,  261 
Nervous  cough,  197 

diseases  in  school  children,  512 

system,  care  of,  20 
diseases  of,  295 
examination  of,  295 
Nervousness    in    school    children, 

513 
Neuritis,  hypertrophic  interstitial, 
365 

multiple,  366 
Newborn,  care  of,  17 

diseases  of,  50 

fatty  degeneration  of,  62 

lip  reflex  of,  300 

puerperal  fever  of,  54 

sepsis  of,  54 
Night  terrors,  314 
Nipples,  care  of,  in  summer,  527 
Nodding  spasm,  309,  310 
Nodes,  lymph-,  42 
Noma,  135,  273 
Normoblasts,  231 

Nose,    examination   of,    in    school 
children,  510 

irritating     discharge     from,     in 
school  children,  514 

running,  in  school  children,  514 
Nucleated  red  cells,  231 
Nursery,  21 
Nursing,  good,  483 

bottle,  hygienic,  95 
Nutrition,  diseases  of,  114 
Nystagmus,  39,  309 


Oak  rash,  280 
Obstruction  of  intestine,  65 
Oleoresin  of  male  fern,  496 
Omental  cyst,  178 
Ophthalmia  neonatorum,  56 
Ophthalmoscopic  examination,  39 
Opiates,  484 

Opisthotonos,  cervical,  311 
Opium,  484 

Osteogenesis  imperfecta,  471 
Osteomyelitis,  acute,  471 
Ostitis,  tuberculous,  463 


546 


INDEX. 


Ostitis,   tuberculous,  articular,  of 
hip,  465 
of  knee,  468 
Otitis,  294 
Oxyuris  vermicularis,  173 

Pachymeningitis,  326 
Pack,  cold,  481 

hot,  503 

mustard,  504 
Pads,  sucking,  40 
Pain,  41 

abdominal,  41 

in  arms,  42 

in  both  sides  of  body,  42 

in  inner  side  of  knee,  41 

in  legs,  42 

in  thigh,  41 

pleuritic,  41 
Palate,  40 

bifid,  130 

cleft,  129 

high-arching  of,  40 
Paleness  in  school  children,  515 
Palpation  of  abdomen,  46 
Pamphlet,  sample,  of  information 

for  distribution  among  poor  in 

summer,  526 
Papilloma  of  larynx,  191 
Paralysis,  acute  ascending,  360 
wasting,  419 

asthenic  bulbar,  337 

BelTs,  368 

birth,  323 

cerebral,  323,  334 

developmental,  352 

diphtheritic,  368 

Erb's,  324 

essential,  of  children,  419 

facial,  368 

of  newborn,  326 

glosso-labial-laryngeal,  362 

in  school  children,  513 

juvenile  general,  352 

Landry's,  360,  420 

of  arm,  324 

pressure,  of  spinal  cord,  357 

pseudohypertrophic,  363 

spinal,  324 
infantile,  419 
Paralytic  idiocy,  339 
Paraplegia,  284 


Paraplegia,  Pott's,  357 
Parasitic  ointment,  501 
Parotitis,  epidemic,  394 
Parry's  disease,  320 
Pasteurizer,  Freeman's,  96 
Pavor  nocturnus,  314 
Pearls,  epithelial,  40 
Pediatric  literature,  531 
Pediculosis,  288 
Pellagra,  473 
Pelletierin  tannate,  496 
Pemphigus,  60 

syphilitic,  61 

traumatic,  61 
Pepsin,  491 
Pericarditis,  219 

chronic  adherent,  222 
Perinephritis,  270 
Perisplenitis,  253 
Peritonitis,  176 

acute,  176 

chronic,  177 

tuberculous,  437 
Peritonsillar  abscess,  139 
Perleche,  128 
Pernicious  anemia,  238 
Peroneal  muscular  atrophy,  365 
Pertussis,  390.     See  also   Whoop- 
ing-cough. 
Petit  mal,  302 
Pharyngitis,  acute,  142 
Pharynx,  diseases  of,  128 
Phimosis,  271 
Phlebitis,  sinus,  330 
Phlegmonous  tonsillitis,  139 
Photophobia,  296 
Phthiriasis,  288 
Physical  defects  in  school  children, 

513 
Physiologic  albuminuria,  255 

peculiarities,  20 
Pick's  paste,  500 
Pigeon  breast,  34 
Pinworm,  173 
Plantar  reflex,  298 
Pleural  effusions,  46 
Pleurisy,  210 
Pleuritic  pains,  41 
Pleuropneumonia,  208 
Pneumococcal  arthritis,  470 
Pneumococcic  infections,  epidemic, 

425 


INDEX. 


547 


Pneumonia,  198 

blood-changes  in,  236 

bronchopneumonia,  199 

catarrhal,  199 

cheesy,  429 

chronic  interstitial,  208 

creeping,  207 

croupous,  205 

facial  expression  in,  38 

hypostatic,  207 

lobar,  205 

lobular,  199 

prolonged,  207 

white,  441 
Pneumopericardium,  222 
Poikilocytes,  231 
Poison-ivy  rash,  280 
Poliomyelitis,  anterior,  419 

chronic  anterior,  362 
Polychromasia,  231 
Polymorphonuclear      neutrophilic 

leukocytes,  233 
Polynuclears,  233 
Polypus,  mucous,  of  umbilicus,  68 
Polyuria,  259 
Porrigo  favosa,  291 
Position,  42 
Potassium  acetate,  493 

bitartrate,  493 

chlorate,  489 
Pott's  disease,  463 

retropharyngeal  abscess  from, 
141 

paraplegia,  357 
Premature  infants,  34 
Preparation  of  milk,  96 
Prepuce,  adherent,  271 
Prescriptions,  milk,  81 
Pressure  paralysis  of  spinal  cord, 

357 
Prickly  heat,  281 
Proctitis,  175 

Progressive  central  muscular  atro- 
phy, 360 

muscular  dystrophy,  362 

neuritic  muscular  atrophy,  365 
Prolapse  of  anus,  174 
Prolonged  pneumonia,  207 
Proteins  of  milk,  77 
Pseudohypertrophic  paralysis,  363 
Pseudohypertrophy,  muscular,  363 
Pseudoleukemia,  241,  246 


Pseudoparalysis,  300 
Psychic  epilepsy,  303 
Puerperal  fever  of  newborn,  54 
Pulse,  46 
Pump,  breast-,  70 
Puncture,  lumbar,  46,  417 
Pupils,  39 

contracted,  39 

dilated,  39 

inequality  of,  39 
Purpura,  243 

fulminans,  245,  251 

giant,  244 

hemorrhagica,  244 

Henoch's,  245 

rheumatica,  244 
Purpuric  diseases,  244 
Pus  in  urine,  257 
Pyelitis,  267 
Pyemia,  54 

Pylorus,  congenital  stenosis  of,  150 
Pyogenic  diseases,  54 
Pyuria,  257 

Quiet,  482 
Quinin,  499 
Quinsy,  139 

Rachitis,  120 

adolescent,  123 
Reaction,  electrical,  300 

of  milk,  79 

of  stools,  107 
Rectum,  deformities  of,  152 

diseases  of,  174 
Red  cells,  235 

nucleated,  231 
number  of,  231 

gum,  281 

stools,  107 
Reduced  iron,  488 
Reflex  cough,  197 

lip,  of  newborn,  300 

plantar,  298 

skin,  297 
Refrigerator,  home-made,  529- 
Regurgitation,  aortic,  227 

mitral,  225 

tricuspid,  227 
Remedies  for  local  inflammations, 

501 


548 


INDEX. 


Remedies  for  skin  diseases,  499 
Renal  calculi,  269 
Respiration,  46 

artificial,  Laborde's  method,  52 
Schultze's  method,  51,  52 
Respiratory  organs,  tuberculosis  of, 
429 

system,  181 
Rest  in  bed,  482 
Retraction  of  head,  311 
Retro-esophageal  abscess,  142 
Retropharyngeal  abscess,  140 
from  Pott's  disease,  141 
idiopathic,  141 
Rheumatic  purpura,  244 
Rheumatism,  457 

acute,  470 
Rhinitis,  acute,  182 

chronic,  183 

membranous,  184 

syphilitic,  184 
Rhubarb,  492 
Rickets,  120 

fetal,  350 
Rickety  rosary,  121 
Riga's  disease,  131 
Rigors,  43 
Ringworm,  290 

in  school  children,  514 
Rosary,  rickety,  121 
Roseola,  epidemic,  381 
Rotary  spasm,  309 
Rotheln,  381 
Roundworm,  173 
Rubella,  381 

morbilliforme,  382 

scarlatiniforme,  382 
Running  eyes  in  school  children, 
514 

nose  in  school  children,  514 

Sago  spleen,  252 
Saint  Vitus'  dance,  307 
Salicylic  acid,  497 
Salipyrin,  498 
Salivary  glands,  29 
Salol,  498 
Salophen,  498 
Salt  bath,  503 

rheum,  278 

solution,  subcutaneous  injection, 
505 


Salts  of  milk,  78 

Salvarsan    in    congenital    syphilis, 

446 
intramuscular     injection,     sites 

for,  447 
Santonin,  496 
Sarcoma  of  kidney,  267 

of  stomach,  151 
Scabies,  289 

in  school  children,  514 
Scalp,  seborrhea  of,  282 
Scapula,  wing,  in  progressive  mus- 
cular atrophy,  363,  364 
Scarlatina,  371 
Scarlet  fever,  371 

anginoid,  373 

blood-changes  in,  236 

danger  after  exposure  to,  516 

in  school  children,  510,  515 

malignant,  373 

return  to  school  after,  517 
Schonlein's  disease,  244 
School  children,  diet  of,  102 

medical  inspection  of,  508 
hygiene,  508 
Schultze's     method     of     artificial 

respiration,  51,  52 
Sclerema,  68 

Sclerosis,  amyotrophic  lateral,  362 
Scorbutus,  124 
Scurvy,  124 
Seatworm,  173 
Sebaceous  glands,  29 
Seborrhea  of  scalp,  282 
Second  year,  feeding  in,  97 
Senega,  494 
Senna,  492 
Senses,  special,  26 
Sepsis  of  newborn,  54 
Septic  infections,  54 

thrombosis,  330 
Septicemia,  54 
Shape  of  hand,  48 

of  head,  25 
Shortness    of    breath    in    school 

children,  515 
Sight,  26 
Sign,  Chvostek's,  299 

Kernig's,  298 
Simple  atrophy,  115 
Singultus,  310 
Sinus  phlebitis,  330 


INDEX. 


549 


Sinus  thrombosis,  330 
Size  of  head,  25 
Skm,  43 

care  of,  19 

diseases,  277 

in  school  children,  514 
remedies  for,  499 

eruptions  in  school  children,  514 

reflexes,  297 
Sleep,  20 

disorders  of,  314 

for  baby  in  summer,  526 
Sleeplessness,  42 
Sleep-walking,  314 
Small-pox,   danger  after  exposure 
to,  516 

return  to  school  after,  517 
Smell,  27 
Soda  bath,  503 

Sodiotheobromin  salicylate,  493 
Sodium  bicarbonate,  496 

citrate,  94 

salicylate,  497 
Somnambulism,  314 
Somnifacients,  485 
Soy  bean,  94 
Spasm,  catarrhal,  of  larynx,  187 

habit,  309 

in  school  children,  512 

nodding,  309,  310 

rotary,  309 

vesical,  274 
Spasmodic  affections,  309 

croup,  187 

laryngitis,  187 
Spasmus  nutans,  310 
Spastic  diplegia,  334 
Special  senses,  26 
Speech,  27 

disturbances,  315,  316 

nasal,  315 
Spice  bag,  504 
Spina  bifida,  355 
Spinal  cord,  diseases  of,  355 
malformations  of,  355 
pressure  paralysis  of,  357 
tumors  of,  358 

meningitis,  356 

paralysis,  324 
infantile,  419 
Spine,  31 

caries  of,  463 


Spirit  of  mindererus,  493 
Spleen,  251 

amyloid,  252 

congestion  of,  252 

enlargement  of,  252 

floating,  253 

new  growths  of,  253 

sago,  252 
Splenic  anemia,  241 
Splenitis,  253 

Splenomegaly,  primary,  253 
Spondylitis  deformans,  462 
Sponge,  cold,  481 
Spontaneous  hemorrhage,  64 
Sprays,  nasal,  505 
Sprue,  133 
Sputum,  41 
Squills,  494 
Stammering,  315 
Staphylococcus  vaccines,  506 
Starch  bath,  503 
Starr's  table,  91,  92 
Stationary  weight,  110 
Status  epilepticus,  304 

lymphaticus,  247 

thymicus,  247 
Steam  atomizer,  188 
Stenosis,  aortic,  226 

congenital,  of  pylorus,  150 

mitral,  226 
Sterilizer,  Arnold,  96 
Sternomastoid,  hematoma  of,  64 
Stigmata  of  degeneration,  352 
Still's  disease,  461 
Stimulants,  485 
Stomach,  31 

carcinoma  of,  151 

dilatation  of,  149 

diseases  of,  144 

hemorrhage  from,  151 

lymphadenoma  of,  151 

sarcoma  of,  151 

tumors  of,  151 

ulcer  of,  151 

washing,  501 
Stomachics,  490 
Stomach-tube,  feeding  by,  111 
Stomatitis,  aphthous,  133 

catarrhal,  133 

gangrenous,  135 

herpetic,  133 

ulcerative,  134 


550 


INDEX. 


Stomatitis,  vesicular  follicular,  133 
Stools,  black,  107,  108 

blackish-brown,  108 

blood  in,  49 

examination  of,  48 

green,  108 

incontinence  of,  176 

infants,  106 

mucus  in,  48 

reaction  of,  107 

red,  107 

white,  49,  107 
Strabismus,  39 
Streptococcus  vaccines,  506 
Stridor,  congenital  laryngeal,  192 
Strophulus,  281 
Strychnin,  486 
Stupes,  turpentine,  504 
Stuttering,  315,  316 
Subcutaneous     injection     of     salt 

solution,  505 
Sucking  ringers,  319 

pads,  40 
Sudden  death,  49 
Sugar  in  urine,  257 

of  milk,  78 
Sulcus,  Harrison's,  34 
Sulphate  of  magnesia,  491 
Sulphonal,  485 
Summer  complaint,  157 

diarrhea,  157 
Suppurative  appendicitis,  169 

synovitis,  acute,  462 
Sutures,  closure  of,  22 
Swallowing,  tongue,  131 
Sweat  glands,  29 

Swelling  of  face,  hands,  or  legs  in 
school  children,  514 

of  neck  in  school  children,  515 

white,  468 
Sydenham's  chorea,  307 
Syndrome,  Erb-Goldflam,  337 

Frohlich's,  253 
Synovitis,  acute,  suppurative,  462 
Syphilis,  440 

acquired,  440 

congenital,  441 
of  joints,  470 

hereditary,  441 
late,  448 
Syphilitic  adenitis,  250 

hepatitis,  54 


Syphilitic  laryngitis,  191 
pemphigus,  61 
rhinitis,  184 

Syringomyelia,  358 

Syringomyelocele,  355 

Syrup  of  cinchona  alkaloids,  499 

Systolic  murmur  over  anterior  fon- 
tanel, 38 

Tabes  mesenterica,  439 
Table,  Ladd's,  89 

of  dosage,  478-480 

Starr's,  91,  92 
Tache  cerebrale,  43,  400,  415 
Taenia  cucumerina,  172 

eUiptica,  172 

flava  punctata,  172 

mediocanellata,  171 

saginata,  171 

solium,  172 
Taka-diastase,  491 
Tannin,  497 
Tapeworms,  171 
Tapir  face,  363 
Tartar  emetic,  494 
Taste,  27 

Technic  of  modifying  milk,  95 
Teeth,  28 

care  of,  18 

Hutchinson's,  448 

in  school  children,  511 

mercurial,  29 
Temperature,  43-45 

of  bath,  18 
Temporary  (milk)  teeth,  eruption 
of,  28 

teeth,  care  of,  18 
Tension  of  anterior  fontanel,  38 
Tent,  croup,  187 
Terpin  hydrate,  494 
Testicles,  31 

undescended,  271 
Tests,  tuberculin,  427 
Tetanus,  58,  59 
Tetany,  305 
Tetter,  278 
Therapeutics,  476 
Thigh,  pain  in,  41 
Thomsen's  disease,  310 
Thorax.     See  Chest. 
Throat,  examination  of,  in  school 

children,  510 


INDEX. 


551 


Thrombosis,  230 

cachectic,  330 

inflammatory,  330 

of  sinuses,  330 

septic,  330 
Thrush,  133 
Thymic  asthma,  250 
Thymus,  31 

diseases  of,  250 
Thyroid,  enlarged,  320 
Tic,  313 

convulsive,  313 
Tinea  circinata,  290 

favosa,  291 

tonsurans,  291 

tricophytina,  290 
Tongue,  bifid,  130 

congenital  hypertrophy  of,  130 

deformities  of,  130 

epithelial  desquamation  of,  130 

swallowing,  131 
Tongue-tie,  130 
Tonics,  487 
Tonsillitis,  chronic,  140 

croupous,  137 

follicular,  137 

in  school  children,  510 

phlegmonous,  139 

ulceromembranous,  137 
Tonsils,  chronic  hypertrophy  of,  130 

diseases  of,  137 
Top-milk  method,  83 
Torticollis,  311 
Touch,  27 

Tracheotomy  in  diphtheria,  407 
Training  bladder,  19 

bowels,  19 

early,  of  deaf  and  dumb  children, 
27 

of  blind  children,  26 
Transmission  of  infectious  diseases, 

370 
Traumatic  hemorrhage,  63 

pemphigus,  61 
Tremor,  300 
Tricophytosis,  290 
Tricuspid  insufficiency,  227 
Trident  hand,  351 
Trional,  485 
True  croup,  190 
Tuber culin  injections  in  diagnosis, 

427 


Tuberculin    injections    in    treat- 
ment, 507 

tests,  427 
value  of,  428 
Tuberculosis,  425 

acute  miliary,  428 

Calmette's  test  for,  427 

Moro's  test  for,  428 

of  bronchial  lymph-nodes,  436 

of  intestines,  437 

of  kidney,  440 

of  lymph-nodes,  435 

of  mesenteric  lymph-nodes,  439 

of  respiratory  organs,  429 

tuberculin  in  treatment,  507 

von  Pirquet's  test  for,  427 

Wolff-Eisner  test  for,  427 
Tuberculous  adenitis,  435 

arthritis,  463,  469 

articular  ostitis  of  hip,  465 
of  knee,  468 

bronchitis,  432 

laryngitis,  190 

meningitis,  432 

ostitis,  463 

peritonitis,  448 
Tumors,  diverticulum,  68 

of  brain,  331 

of  larynx,  191 

of  spinal  cord,  358 

of  stomach,  151 
Turpentine  stupes,  504 
Typhoid  fever,  409 

danger  after  exposure  to,  516 

vaccines,  506 
Typhus  abdominalis,  409 


Ulcer  of  frenum,  131 

of  stomach,  151 
Ulcerative  endocarditis,  224 

stomatitis,  134 
Ulceromembranous  tonsillitis,  137 
Umbilical  cord,  care  of,  17 

hernia,  67 
Umbilicus,  adenoma  of,  68 

granuloma  of,  67 

lesions  of,  67 

mucous  polypus  of,  68 
Uncinariasis,  455 
Undescended  testicle,  271 
Urethan,  485 


552 


INDEX. 


Urethritis,  272 

Uric  acid  infarctions,  260 

Urine,  blood  in,  256 

character  of,  254 

collecting,  254 

diminution  of,  258 

drugs  to  render  acid,  498 

in  diabetes,  127 

incontinence  of,  274 

pus  in,  257 

quantity  of,  254 

sugar  in,  256 
Urogenital  antiseptics,  498 
Urotropin,  498 
Urticaria,  285 

giant,  47 
Uvula,  diseases  of,  132 

elongated,  132 
Uvulitis,  132 


Vaccination,  19,  388 
Vaccine  therapy,  506 
Vaccines,  506 

autogenous,  506 

bacillus  coli  communis,  507 

gonococcus,  506 

meningococcus,  506 

staphylococcus,  506 

stock,  506 

streptococcus,  506 

typhoid,  506 
Vaccinia,  388 

Valvular  disease,  chronic,  224 
Varicella,  385 

danger  after  exposure  to,  516 

gangrenosa,  387 

return  to  school  after,  517 
Vasomotor  stimulant,  498 
Vernix  caseosa,  29 
Veronal,  485 
Vertigo,  297 
Vesical  calculi,  274 
Vesicular  follicular  stomatitis,  133 
Vincent   and  Bellot's  reaction   in 

cerebrospinal  meningitis,  417 
Vincent's  disease,  137 
Visceral  hemorrhage,  64 
Volumen  acutum  pulmonum,  209 


Vomiting,  110,  144 

cyclic,  144 

facial  expression  in,  38 

in  school  children,  514 
Von  Pirquet's  test  for  tuberculosis, 

427 
Vulva,  herpes  of,  273 
Vulvitis,  gangrenous,  273 
Vulvovaginitis,  272 

Warner's  law  of  coincident  de- 
velopment, 343 

Washes,  nasal,  505 

Wasting  disease,  115 
paralysis,  acute,  419 

Water  for  baby  in  summer,  527 
on  brain,  332,  432 

Waters,  aromatic,  490 

Waxy  kidney,  266 

Weight,  21,  24 
loss  of,  109 
stationary,  110 

Werlhoff's  disease,  244 

Wet-nursing,  75 

Wetting  the  bed,  274 

White  blood-cells,  231,  235 
abnormal,  233 
pneumonia,  441 
stools,  49,  107 
swelling,  468 

Whooping-cough,  390 
antispasmodics  for,  498 
blood-changes  in,  237 
danger  after  exposure  to,  516 
in  school  children,  516 
return  to  school  after,  517 

Whytt's  disease,  432 

Winckel's  disease,  62 

Wing  scapula  in  progressive  mus- 
cular atrophy,  363,  364 

Wolff-Eisner  test  for  tuberculosis, 
427 

Word-blindness,  congenital,  26,  39 

Worms,  intestinal,  171 

Wry-neck,  311 

Wyllie's  physiologic  alphabet,  316 

Xeroderma,  277 


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Edited  by  Nath'l  Bowditch  Potter,   M.D. 


A  Treatise  on  Diagnostic  Methods  of   Examination. 

By  Prof.  Dr.  H.  Sahli,  of  Bern.  Edited,  with  additions,  by 
Nath'l  Bowditch  Potter,  M.D.,  Assistant  Professor  of  Clinical 
Medicine,  Columbia  University.  Octavo  of  1225  pages,  pro- 
fusely illustrated.     Cloth,  $6.50  net. 

SECOND  EDITION,  RESET 
Lewellys  F.  Barker,  M.  D. 

Professor  of  Medicine,  Johns  Hopkins  University 
"  I  am  delighted  with  it,  and  it  will  be  a  pleasure  to  recommend  it  to  our  students  in 
the  Johns  Hopkins  Medical  School." 


Friedenwald  &  Ruhrah  on  Diet 

Diet  in  Health  and  Disease.  By  Julius  Friedenwald, 
M.  D.,  Professor  of  Diseases  of  the  Stomach,  and  John  Ruhrah, 
M.  D.,  Professor  of  Diseases  of  Children,  College  of  Physicians 
and  Surgeons,  Baltimore.   Octavo  of  85  7  pages.     Cloth,  $4.00  net. 

NEW  (4th)  EDITION 

Dietetic  management  in  all  diseases  in  which  diet  plays  a  part  in  treat- 
ment is  carefully  considered,  the  articles  on  diet  in  diseases  of  the  digestive 
organs  containing  numerous  diet  lists  and  explicit  instructions  for  administra- 
tion. The  feeding  of  infants  and  children,  of  patients  before  and  after  anes- 
thesia and  surgical  operations,  are  all  taken  up  in  detail. 

"  It  seems  to  me  that  you  have  prepared  the  most  valuable  work  of  the  kind  now  avail- 
able. I  am  especially  glad  to  see  the  long  list  of  analyses  of  different  kinds  of  food." — 
George  Dock,  M.  D.,  Tulane  University  of  Louisiana. 


Eg'gleston's  Prescription  Writing 


This  new  work  is  a  crystallization  of  Dr.  Eggleston's  long  experience 
in  teaching  this  subject.  It  covers  the  entire  field  in  a  most  practical  way, 
taking  up  grammar,  construction,  dosage,  vehicles,  incompatibility,  ad- 
ministration, etc. 

i6mo  of  115  pages.      By  Cary  Eggleston,  M.  D.,  Instructor  in  Pharmacology  at 
Cornell  University  Medical  School.     Cloth  $1.00  net. 


PRACTICE  OF  MEDICINE 


Kemp  on  Stomach, 
Intestines,  and  Pancreas 

Diseases  of   the   Stomach,   Intestines,   and    Pancreas, 

By  Robert  Coleman  Kemp,  M.  D.,  Professor  of  Gastrointes- 
tinal Diseases  at  the  New  York  School  of  Clinical  Medicine. 
Octavo  of  1025  pages,  with  377  illustrations.  Cloth,  $6.50  net; 
Half  Morocco,  $8.00  net. 

NEW  (2d)  EDITION 

It  is  the  practitioner  who  first  meets  with  these  cases,  and  it  is  he  upon 
whom  the  burden  of  diagnosis  rests.  After  the  diagnosis  is  established,  the 
practitioner,  if  properly  equipped,  could  frequently  treat  the  case  himself 
instead  of  transferring  it  to  a  specialist.  This  work  is  intended  to  equip  the 
practitioner  with  this  end  in  view. 

The  Therapeutic  Gazette 

*'  The  therapeutic  advice  which  is  given  is  excellent.  Methods  of  physical  and 
chemical  examination  are  adequately  and  correctly  described." 


Deaderick  on   Malaria 


Practical  Study  of  Malaria.  By  William  H.  Deaderick, 
M.  D.,  Member  American  Society  of  Tropical  Medicine. 
Octavo   of   402    pages,    illustrated.      Cloth,    $4.50   net; 

Frank  A.  Jones,  M.  D.,  Memphis  Hospital  Medical  College. 

"  Dr.  Deaderick's  book  is  up  to  date  and  the  subject  matter  is  well  arranged.  We 
have  been  waiting  for  many  years  for  such  a  work  written  by  a  man  who  sees  malaria  in 
all  its  forms  in  a  highly  malarious  climate." 


Niles  on  Pellagra 


TWO  PRINTINGS 
IN  FIVE  MONTHS 


Pellagra.  By  George  M.  Niles,  M.  D.,  Professor  of  Gastro- 
enterology and  Therapeutics,  Atlanta  School  of  Medicine.  Oc- 
tavo of  253  pages,  illustrated.     Cloth,  $3.00  net. 

This  is  a  book  you  must  have  to  get  in  touch  with  the  latest  advances  con- 
cerning this  disease.  It  is  the  first  book  on  the  subject  by  an  American 
author,  and  the  first  in  any  language  adequately  covering  diagnosis  and 
treatment. 


io  SAUNDERS'    BOOKS    ON 

Faught's  Blood-Pressure 

Blood=Pressure   from    the    Clinical    Standpoint.      By 

Francis  A.  Faught,  M.  D.,  formerly  Director  of  the  Laboratory 
of  Clinical  Medicine  of  the  Medico-Chirurgical  College  of  Phila- 
delphia.    Octavo  of  281  pages,  illustrated.      Cloth,  $3.00  net. 

THREE  PRINTINGS  IN  SIX  MONTHS 

Dr.  Faught's  book  is  designed  for  practical  help  at  the  bedside.  It  meets 
the  urgent  needs  of  the  general  practitioner,  who  heretofore  had  no  book  to 
which  to  turn  in  case  of  emergency.  Every  effort  has  been  made  to  provide 
here  a  practical  guide,  full  of  information  of  a  clinical  nature,  and  presented 
in  a  way  readily  available  for  daily  use  by  the  busy  man.  Besides  the  actual 
technic  of  using  the  sphygmomanometer  in  diagnosing  disease,  Dr.  Faught 
has  included  a  brief  general  discussion  of  the  process  of  circulation.  The 
practical  application  of  sphygmomanometric  findings  within  recent  years  makes 
it  imperative  for  every  medical  man  to  have  close  at  hand  an  up-to-date  work 
on  this  subject, 

Anders  and  Boston's  Medical 

Diagnosis 

A  Text-Book  of  Medical  Diagnosis.  By  James  M.  An- 
ders, M.D.,  Ph.D.,  LL.  D.,  Professor  of  the  Theory  and  Prac- 
tice of  Medicine  and  of  Clinical  Medicine,  and  L.  Napoleon 
Boston,  M.  D.,  Professor  of  Physical  Diagnosis,  Medico-Chirur- 
gical College,  Philadelphia.  Octavo  of  1248  pages,  with  466 
illustrations.     Cloth,  $6.00  net. 

JUST  OUT— NEW  (2d)    EDITION 

This  new  work  is  designed  expressly  for  the  general  practitioner.  The 
methods  given  are  practical  and  especially  adapted  for  quick  reference.  The 
diagnostic  methods  are  presented  in  a  forceful,  definite  way  by  men  who  have 
had  wide  experience  at  the  bedside  and  in  the  clinical  laboratory. 

The  Medical  Record 

"The  association  in  its  authorship  of  a  celebrated  clinician  and  a  well-known  labora- 
tory worker  is  most  fortunate.      It  must  long  occupy  a  pre-eminent  position." 


PRACTICE  OF  MEDICINE  II 

Ward's    Bedside    Hematology 

Bedside  Hematology.  By  Gordon  R.  Ward,  M.  D., 
Fellow  of  the  Royal  Society  of  Medicine,  London,  England. 
Octavo  of  394  pages,  illustrated.  Cloth,  $3.50  net. 

INCLUDING  VACCINES  AND  SERUMS 

Dr.  Ward's  work  is  designed  to  be  of  service  to  the  man  in  general  prac- 
tice. It  gives  you  the  exact  technic  for  obtaining  the  blood  for  examination, 
the  making  of  smears,  making  the  blood-count,  finding  coagulation  time,  etc. 
Then  it  takes  up  each  disease,  giving  you  the  general  pathology,  etiology, 
bearings  of  age  and  sex,  onset,  symptomatology,  course,  clinical  varieties, 
complications,  diagnosis,  and  treatment  (drug,  diet,  rest,  vaccines  and  serums, 
jr-ray,  operations,  etc.).  There  is  a  special  chapter  devoted  to  the  medical 
treatment  of  hemorrhage,  giving  you  the  exact  doses  of  the  various  drugs  in- 
dicated and  the  methods  of  their  administration,  the  serum  treatment,  trans- 
fusion, etc.  Another  chapter  is  devoted  to  the  value  of  blood  findings  in 
surgical  diagnosis,  pointing  out  their  value  in  differentiating  benign  from 
malignant  growths,  infectious  from  other  diseases,  appendicitis  from  typhoid 
fever. 


Smith's  What  to  Eat  &  Why 

What  to  Eat  and  Why.  By  G.  Carroll  Smith,  M.D., 
Boston.     1 2mo  of  312  pages.     Cloth,  $2.50  net. 

FOR  THE  PRACTITIONER 

With  this  book  you  no  longer  need  send  your  patients  to  a  specialist  to 
be  dieted — you  will  be  able  to  prescribe  the  suitable  diet  yourself,  just  as  you 
do  other  forms  of  therapy.  Dr.  Smith  gives  "the  why"  of  each  statement 
he  makes.  It  is  this  knowing  why  which  gives  you  confidence  in  the  book, 
which  makes  you  feel  that  Dr.  Smith  knows. 


Slade's  Physical  Examination  &  Diagnostic  Anatomy 

Physical  Examination  and  Diagnostic  Anatomy.— By  Charles 
B.  Slade,  M.D.,  Chief  of  Clinic  in  General  Medicine,  University  and 
Bellevue  Hospital  Medical  College.  i2mo  of  146  pages,  illustrated. 
Cloth,  $1.25  net. 


12  SAUNDERS'    BOONS  ON 


Stevens'  Therapeutics  Fifth  Edition 

A  Text-Book  of  Modern  Materia  Medica  and  Therapeutics. 
By  A.  A.  Stevens,  A.M.,  M.D.,  Lecturer  on  Physical  Diagnosis  in  the 
University  of  Pennsylvania.     Octavo  of  675  pages.     Cloth,  #3.50  net. 

Dr.  Stevens'  Therapeutics  is  one  of  the  most  successful  works  on  the  subject  ever 
published.  In  this  new  edition  the  work  has  undergone  a  very  thorough  revision, 
and  now  represents  the  very  latest  advances. 

The  Medical  Record,  New  York 

"  Among  the  numerous  treatises  on  this  most  important  branch  of  medical  practice, 
this  by  Dr.  Stevens  has  ranked  with  the  best." 

Butler's  Materia  Medica  Sixth  Edition 

A  Text-Book  of  Materia  Medica,  Therapeutics,  and  Pharma- 
cology. By  George  F.  Butler,  Ph.G.,  M.D.,  Professor  and  Head 
of  the  Department  of  Therapeutics  and  Professor  of  Preventive  and 
Clinical  Medicine,  Chicago  College  of  Medicine  and  Surgery,  Medical 
Department  Valpariso  University.  Octavo  of  702  pages,  illustrated. 
Cloth,  #4.00  net;  Half  Morocco, $5.50  net. 

For  this  sixth  edition  Dr.  Butler  has  entirely  remodeled  his  work,  a  great  part  hav- 
ing been  rewritten  All  obsolete  matter  has  been  eliminated,  and  special  attention 
has  been  given  to  the  toxicologic   and  therapeutic  effects  of  the  newer  compounds. 

Medical  Record,  New  York 

"  Nothing  has  been  omitted  by  the  author  which,  in  his  judgment,  would  add  to 
the  completeness  of  the  text." 

Sollmann's  Pharmacology  Second  Edition 

A  Text-Book  of  Pharmacology.  By  Torald  Sollmann,  M.D., 
Professor  of  Pharmacology  and  Materia  Medica,  Western  Reserve  Uni- 
versity.    Octavo  of  1070  pages,  illustrated.     Cloth,  $4.00  net. 

The  author  bases  the  study  of  therapeutics  on  systematic  knowledge  of  the  nature 
and  properties  of  drugs,  and  thus  brings  out  forcibly  the  intimate  relation  between 
pharmacology  and  practical  medicine. 

J.  F.  Fotheringham,  M.D.,  Trinity  Medical  College,  Toronto. 

"The  work  certainly  occupies  ground  not  covered  in  so  concise,  useful,  and  scien- 
tific a  manner  by  any  other  text  I  have  read  on  the  subjects  embraced." 

Amy's  Pharmacy 

Principles  of  Pharmacy.  By  Henry  V.  Arny,  Ph.  G.,  Ph.  D., 
Professor  of  Pharmacy,  New  York  College  of  Pharmacy.  Octavo  of 
1175  pages,  with  246  illustrations.      Cloth.  $5.00  net. 

George  Reimann,  Ph.  G.,  Secretary  of  the  New  York  State  Board  0/ Pharmacy. 

"  I  would  say  that  the  book  is  certainly  a  great  help  to  the  student,  and  I  think  it 
ought  to  be  in  the  hands  of  every  person  who  is  contemplating  the  study  of  pharmacy. 


THERAPEUTICS  AND   MATERIA  MEDICA  13 


Hinsdale's   Hydrotherapy 

Hydrotherapy  :  A  Treatise  on  Hydrotherapy  in  General ; 
Its  Application  to  Special  Affections ;  the  Technic  or  Processes 
Employed,  and  the  Use  of  Waters  Internally.  By  Guy  Hinsdale, 
M.  D.,  Fellow  of  the  Royal  Society  of  Medicine  of  Great  Britain. 
Octavo  of  466  pages,  illustrated.       Cloth, $3. 50  net. 

The  Medical  Record 

"  We  cannot  conceive  of  a  work  more  useful  to  the  general  practitioner  than  this,  nor 
one  to  which  he  would  resort  more  frequently  for  reference  and  guidance  in  his  daily 
work." 


Kelly's  Cyclopedia  of  American 
Medical  Biography 

Cyclopedia  of  American  Medical  Biography.  By  How- 
ard A.  Kelly,  M.  D.,  Johns  Hopkins  University.  Two  octavos 
of  525  pages  each,  with  portraits.  Per  set:  Cloth,  $10.00  net; 
Half  Morocco,  $13.00  net. 

Dr.  Kelly,  in  these  two  handsome  volumes,  presents  concise,  yet  com- 
plete biographies  of  those  men  and  women  who  have  contributed  note  wor- 
thily to  the  advancement  of  medicine  in  America.  Dr.  Kelly's  reputation  for 
painstaking  care  assures  accuracy  of  statement.  There  are  about  one  thousand 
biographies  included. 

Swan's  Prescription-writing  and  Formulary 

Prescription-writing  and  Formulary.  By  John  M.  Swan, 
M.D.,  Director  Glen  Springs  Sanitarium,  Watkins,  N.  Y.  I2mo  of  185 
pages.      Flexible  cloth,  $1.25  net. 

Stewart's    Pocket    Therapeutics    and    Dose- 
book  New  (4th)  Edition 

Pocket  Therapeutics  and  Dose-book.  By  Morse  Stewart,  Jr., 
M.D.     32mo  of  263  pages.      Cloth,  $1.00  net. 

Bohm  and  Painter's  Massage 

Massage.  By  Max  Bohm,  M.  D.,  of  Berlin,  Germany.  Edited, 
with  an  Introduction,  by  Charles  F.  Painter,  M.  D.,  Professor  of 
Orthopedic  Surgery  at  Tufts  College  Medical  School,  Boston.  Octavo 
of  91  pages,  with  97  practical  illustrations.     Cloth,  $1.75  net« 


14  SAUNDERS'    BOOKS   ON 


GET  Amo*»Ir^n  THE  NEW 

THE  BEST  AlllcnCan  STANDARD 

Illustrated   Dictionary 

The  New  (7th)  Edition,  Reset 

The  American  Illustrated  Medical  Dictionary.     By  W.  A. 

Newman  Dorland,  M.  D.,  Editor  of  "The  American  Pocket 
Medical  Dictionary."  Octavo  of  1 107  pages.  Flexible  leather, 
$4.50  net;  with  thumb  index,  $5.00  net. 

OVER  5000  NEW  WORDS 

Howard   A.    Kelly,    M.  D.,  Johns  Hopkins  University ,  Baltimore. 

"  Dr.  Dorland's  dictionary  is  admirable.      It  is  so  well  gotten  up  and  of  such  conve- 
nient size.     No  errors  have  been  found  in  my  use  of  it." 


Thornton's  Dose-Book  Fourth  Edition 

Dose-Book  and  Manual  of  Prescription-Writing.  By  E.  Q. 
Thornton,  M.  D.,  Assistant  Professor  of  Materia  Medica,  Jefferson 
Medical  College,  Philadelphia.  Post-octavo,  392  pages,  illustrated. 
Flexible  leather,  $2.00  net. 

"  It  will  afford  me  much  pleasure  to  recommend  the  book  to  my  classes,  who  often 
fail  to  find  such  information  in-  their  other  text-books." — C.  H.  Miller,  M.D., 
Professor   of  Pharmacology,    Northwestern  University  Medical  School,  Chicago. 

Lusk    On    Nutrition  Second  Edition 

Elements  of  the  Science  of  Nutrition.  By  Graham  Lusk, 
Ph.D.,  Professor  of  Physiology  in  Cornell  University  Medical  School. 
Octavo  of  402  pages.     Cloth,  $3.00  net. 

"  I  shall  recommend  it  highly.  It  is  a  comfort  to  have  such  a  discussion  of  the 
subject." — Lewellvs  F.  Bakkeh,  M.  D.,  Professor  of  the  Principles  and  Practice 
of  Medicine,  Johns  Hopkins  University. 

Hatcher  and  Sollmann's  Materia  Medica 

A  Text-Book  of  Materia  Medica  :  including  Laboratory  Exer- 
cises in  the  Histologic  and  Chemic  Examination  of  Drugs.  By  Robert 
A.  Hatcher,  Ph.  G.,  M.  D. ;  and  Torald  Sollmann,  M.  D.  12010 
of  411  pages.     Flexible  leather,  $2.00  net. 

Bridge  on  Tuberculosis 

Tuberculosis.  By  Norman  Bridge,  A.  M.,  M.  D.  i2mo  of  302 
pages,  illustrated,     Cloth,  $1.50  net. 


MATERIA  MEDICA  AND   THERAPEUTICS.  15 

American  Pocket  Dictionary         New  (8thj  Edition 

The  American  Pocket  Mkdicai.  Dictionary.  Edited  by  W. 
A.  Newman  Dorlanu  M.D.  Flexible  leather,  with  gold  edges,  $1.00 
net ;  with  thumb  index,  $1.25  net. 

Pusey  and  Caldwell  on  X-Rays  Second  Edition 

The  Practical  Application  of  the  Rontgen  Rays  in  Thera- 
peutics and  Diagnosis.  By  William  Allen  Pusey,  A.  M.,  M.  D., 
and  Eugene  W.  Caldwell,  B.  S.  Octavo  of  625  pages,  with  200 
illustrations.     Cloth,  $5.00  net. 

Cohen   and    Eshner's    Diagnosis.     Second  Revised  Edition 

Essentials  of  Diagnosis.  By  S.  Solis-Cohen,  M.  D.,  and  A.  A. 
Eshner,  M.  D.  Post-octavo,  382  pages  ;  55  illustrations.  Cloth,  $1.00 
net.      In  Saunders1   Question- Compend  Series. 

Seventh. 

Morris*  Materia  Medica  and  Therapeutics  Edition 

Essentials  of  Materia  Medica,  Therapeutics,  and  Prescrip- 
tion-Writing. By  Hevry  Morris,  M.  D.  Revised  by  W.  A.  Bas- 
tedo,  M.  D.,  Instructor  in  Materia  Medica  and  Pharmacology,  Columbia. 
University.     i2mo,  300  pages.      Cloth,  $1.00  net.    Sounder?  Contends. 

Williams'  Practice  of  Medicine 

Essentials  of  the  Practice  of  Medicine.  By  W.  R.  Williams, 
M.  D.,  formerly  Lecturer  on  Hygiene  and  Instructor  in  Medicine.  Cornell 
University,  N.  Y.  i2mo  of  460  pages.  Double  number,  #1.75  net.  In 
Saunders'  Question-  Compend  Series, 

Barton  and  Wells'  Thesaurus 

A  Thesaurus  of  Medical  Words  and  Phrases.  By  Wilfred  M. 
Barton,  M.  D.,  and  Walter  A.  Wells,  M.  D.  i2mo  of  534  pages. 
Flexible  leather,  $2.50  net ;  with  thumb  index,  S3. 00  net. 

Goepp's  State  Board  Questions  Third  Edition 

State  Board  Questions  avd  Answers.  By  R.  Max  Goepp, 
M.  D. ,  Professor  of  Clinical  Medicine.  Philadelphia  Polyclinic.  Octavo 
of  715  pages.  Cloth,  $4.00  net. 

Boston's  Clinical  Diagnosis  Second  Edition 

Clinical  Diagnosis.  By  Laboratory  Methods.  By  L.  Napoleon 
Boston,  A.  M.,  M.  D.,  Adjunct  Professor  of  Medicine,  Medico- 
Chirurgical  College,  1  hiladelphia.  Octavo  of  563  pages,  with  330  illus- 
trations, many  in  colors.      Cloth,  S4.00  net. 

Arnold's  Medical  Diet  Charts 

Medical  Diet  Charts.  Prepared  by  H.  D.  Arnold,  M.  D., 
Professor  of  Clinical  Medicine,  Tufts  Medical  College,  Boston.  Single 
charts,  5  cents;  50  charts,  $2.00  net;  500  charts,  £18.00  net;  iooo 
charts,  $30.00  net. 


16  SAUNDERS'    BOOKS    ON   PRACTICE,   Etc. 


Saunders'   Pocket   Formulary  Ninth  Edition 

Saunders'  Pocket     Medical    Formulary.      By    William     M. 

Powell,    M.  D.       Containing   1900    formulas    from    the    best-known 

authorities.  In    flexible    leather,    with   side    index,    wallet,    and   flap. 
$1.75  net. 

Jakob  and  Eshner's  Internal  Medicine  and  Diagnosis 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical  Diag- 
nosis. By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited,  with  additions,  by 
A.  A.  Eshner,  M.  D.  182  colored  figures  on  68  plates,  64  text-cuts, 
259  pages  of  text.     Cloth,  $3.00  net.      In  Saunders1  Hand- Atlas  Series. 

Lockwood's  Practice  of  Medicine    Revised^nd^niarged 

A  Manual  of  the  Practice  of  Medicine.  By  Geo.  Roe  Lock- 
wood,  M.  D.,  Attending  Physician  to  the  Bellevue  Hospital,  New  York 
City.     Octavo,  847  pages,  illustrated.     Cloth,  $4.00  net. 

Fenwick's  Dyspepsia 

Dyspepsia.  By  William  Soltau  Fenwick,  M.  D.,  of  London. 
Octavo  of  485  pages,  illustrated.     Cloth,  $3.00  net. 

Jelliffe's   Pharmacognosy 

An  Introduction  to  Pharmacognosy.  By  Smith  Ely  Jelliffe, 
Ph.  D.,  M.  D.,  Columbia  University,  New  York.  Octavo  of  265  pages, 
illustrated.     Cloth,  $2.50  net. 

Stevens'   Practice   of  Medicine  Ninth  Edition 

A  Manual  of  the  Practice  of  Medicine.  By  A.  A.  Stevens, 
A.  M.,  M.  D.,  Professor  of  Therapeutics  and  Clinical  Medicine,  Woman's 
Medical  College,  Philadelphia.  i2mo,  573  pages,  illustrated.  Flexible 
leather,  $2.50  net. 

Camac's  Epoch=Making  Contributions 

Epoch-making  Contributions  to  Medicine  and  Surgery.  By 
C.  N.  B.  Camac,  M.  D.,  of  New  York  City.  Octavo  of  450  pages, 
with  portraits.     Artistically  bound,  #4.00  net. 

Todd's  Clinical  Diagnosis  Second  Edition 

Clinical  Diagnosis.  By  Tames  Campbell  Todd,  M.D..  Professor 
of  Pathology,  University  of  Colorado,  Denver.  i2mo  of  455  pages, 
illustrated.     Cloth,  $2.25  net. 


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k! 

C28I1  140)  Ml  00 

3  .  •    'K* 


^ 


^e>J?  Va^: 


